High school mentorship journal entry No. 4, AILEEN BI

Today’s Date: Oct.  12, 2011

Total Mentorship Hours: 61.5 hours

Mentorship Research Journal #4

My fourth journal entry begins on Sept. 7, when I returned to shadow at the VCU School of Pharmacy.  Dr. Stevens was conducting a lab with the class, while Dr. Mawyer tested the students’ counseling skills. Dr. Mawyer was a pharmacy resident interested in clinical pharmacy, like that practiced in the Ambulatory Care Clinic, due to her desire to practice “clean medicine.” 

The second-year pharmacy students were required to be able to counsel on Warfarin, a blood thinner used to prevent the formation of blood clots in the blood vessels.  The drug works by blocking Vitamin K, which aids blood clotting.  The students must have had to memorize myriad facts about the drug in order to sufficiently answer questions the patient might have.  Their directions had to be very specific, or else they could be putting their patients at risk.  Most importantly, they must be able to communicate their directions sufficiently, in a manner that was more like a conversation than an order.  In this class activity, Dr. Mawyer played the role of the patient, while the students assumed the pharmacist role. 

In addition to Warfarin, students were also required to research the INR, or International Normalized Ratio, which determines a patient’s risk for bleeding.  The ideal ratio is between two and three; a high INR indicates risk of bleeding, while a low INR indicates the risk of painful clot formation.  If the patient’s INR was too high, then the dosage of Warfarin would be lowered.  Practicing counseling skills required that the students demonstrate their understanding of the medication while preparing them for their future careers.

I participated in another class activity on Sept. 14, which focused on genetic testing.  In this activity, students researched different kinds of genetic tests from different companies.  For example, the company Navigenics offered genetic analysis that could be conducted with a saliva sample.  DeCODE offered genetic tests that could be conducted with skin cells from the side of one’s cheek.  The students were responsible for reviewing these different means of genetic testing and determining which kinds of tests they would recommend to their hypothetical patients.  When making these recommendations, the students kept in mind patient convenience, counseling services provided, level of privacy and confidentiality, and possible test limitations, which are all very important factors for patients.  This activity served to allow students to practice their research skills, which are essential for pharmacists, who must frequently research drugs and pharmaceutical companies as more and more enter the market.

After observing several classes from the students’ perspectives, it was time that I explore pharmacy school education from the teacher’s perspective.  Over the next few Mondays, I mentored with Dr. Donohoe, an assistant professor at the School of Pharmacy.  My task was to help create PowerPoint presentations for her class, using the text “The 200 Most Common Drugs.”  During my time with her, I prepared presentations on cardiovascular agents and lipid-lowering agents.  I relied on the text as my guide– by looking up terms with which I was unfamiliar, I recognized them more easily over time. 

Dr. Donohoe gave me additional help by explaining the terms I did not understand.  Through this process, I came across a slew of new medical terms.  While working on the cardiovascular agent unit, I learned about ACE inhibitors, which treat hypertension and heart failure.  Drugs that fall under this drug group typically end with “–pril.”  ARBs also treat hypertension and heart failure and typically end with “–sartan.”  Amiadorone, which also treats the heart, is known for its many side effects. Clonidine is used to treat hypertension and has to be taken often.  Pertaining to lipid-lowering agents, cholestyramine binds with the gastrointestinal tract to block bile acid, which in turn helps lower cholesterol.  LDL and HDL are two of the main groups of lipoproteins: LDL is more commonly known as the “bad cholesterol” while HDL is the “good cholesterol.”  Myopathy is associated with intense muscle pain.  This experience gave me a small glimpse into the vast amount of vocabulary students must pick up over time in order to function as pharmacists in the work field.

I returned to the Ambulatory Care Clinic on Sept. 20. This time, I mentored with Dr. Mayer, who also works as an assistant professor at the School of Pharmacy.  While reviewing a patient’s medical history, she noticed that he had Oslo-Weber-Rendu Disease but was not familiar with that particular disorder.  I watched her put her researching skills to the task and find out that it is a genetic disorder that causes abnormal blood vessel formation.  On Sept. 28, a patient with hypothyroidism, a condition in which the thyroid gland fails to produce enough thyroid hormone, came into the clinic complaining of symptoms that she believed might have been caused by the medication she had been recently prescribed.  These symptoms included intense swelling of feet, dizziness, and headache. 

The pharmacist with whom I was shadowing at the time allowed me to check the patient’s medications, just like I had seen the residents do at my earlier visits.  I found many of the medications challenging to pronounce, but the patient was very patient and knowledgeable of her medical needs.  The resident suggested that the patient’s swelling might have been caused by amlodipine, which had been prescribed to help lower her blood pressure. 

While in the workroom, I overheard another resident discussing her latest successful motivation interview with one of the physicians.  She explained to me that sometimes motivation interviews are conducted to improve patient compliance.  The patient is asked open-ended questions about his perception of his health and other matters.  The pharmacist must give empathetic responses throughout the interview and focus on assessing the barriers preventing the patient from taking more responsibility for his health, then steer him in the right direction.  She explained that it was essential that the patient understand why he should take care of his health and the steps that will take him to that direction.  She seemed content with her recent achievement, as she expressed how much she liked “making a difference” in that patient’s life.  As someone who views pharmacy as a likely career path, I was encouraged by this reaction.

As my mentorship experience has drawn to a close, I would like to sincerely thank Dr. Ballentine for arranging the numerous shadowing opportunities I received in the Main Hospital, Ambulatory Care Clinic, and School of Pharmacy.  I had initially chosen to pursue a career in pharmacy because I felt that it fit well with my personality, according to the research I had conducted on this field. 

No amount of research, however, could have taught me as much as going directly to the professional scene, where I was able to observe many different types of careers in the pharmaceutical field, from education to ambulatory care.  The students and residents I met along the way were also extremely helpful in informing me about this career path.  Overall, this experience has painted a much clearer picture of the pharmaceutical field than the one with which I had began this mentorship experience.  Now I am much more confident in my decision to pursue a career in pharmacy, and I am very grateful to this experience for allowing me to enter college with this newfound sense of direction.

High school mentorship journal entry No. 3, AILEEN BI

Today’s Date: Sept. 3, 2011

Total Hours to Date:  45 hours

Mentorship Research Journal #3

On Aug. 25, patient rounds with Dr. Gravatt began in the Main Hospital’s prison area, located beneath the main floor.  The inmates housed here had been moved from the local jail in order to receive the kind of medical treatment given to the other patients in the hospital.  Although I did not have the chance to pass the main gate and go on rounds with the rest of the team, it was interesting to watch the team conduct business as usual from behind the gates.  With added distance between me and the team, I could see just how this large group of 10 would appear to the patients and visitors.  Afterward, we moved above ground to the emergency room and checked up on a man who suffered from shortness of breath and had initially been thought to have pneumonia.  The results of a CT scan on his chest had recently arrived, though, confirming that he did not have pneumonia.  The team then ordered a nebulizer for the patient’s asthma, hoping to prevent possible airway inflammation.  When used, the nebulizer would release a mist comprising a mixture of oxygen and other compressed gasses, which would be inhaled by the patient and travel into the lungs. 

Another patient had come out of a surgery for her heart failure, in which a small metal rod had been inserted into her heart to compensate for her useless right atrium.  Dr. Gravatt had to order anticoagulant medication for her.  The medication would serve as a blood thinner, decreasing the probability of blood clotting.  During our lunch break in the workroom, Dr. Gravatt conducted a short lesson with her two accompanying pharmacy students, discussing the differences between PPN and TPN, two types of nutrition that can be given to a patient with an IV.  PPN stands for Peripheral Parenteral Nutrition and is administered in a peripheral IV site in the patient’s arm.  TPN stands for Total Parenteral Nutrition and is administered through a central line, which goes through the patient’s chest.  This difference in IV placement is due to the fact that PPN, compared to TPN, has a lower osmolarity, or concentration of particles.    

On Aug. 26, I was able to observe a dialysis treatment for the first time.  This procedure was administered on a patient whose kidneys could not properly filter out the toxins in his body. Dialysis serves as an artificial kidney for the patient, taking out waste and fluid from the bloodstream and replacing them with dialysis fluid, which consists of potassium, sodium, and calcium in concentrations similar to levels that would be found in healthy blood.  Dialysis is based on the principles of diffusion — because solutes tend to move from high to low concentrations, dialysis fluid can move across a semi-permeable membrane into the patient’s bloodstream, while blood diffuses into a machine. 

The patient’s wife had come to the hospital that day with complaints about the care her husband had been receiving.  The atmosphere became quite tense and awkward at this point because of the manner in which she expressed her complaints, coupled with the fact that she directed all of her complaints toward one specific member of the team, insisting that she failed to treat the patient “as a patient” and ultimately disagreeing with all of the treatments given to her husband.  She was adamant about moving him to a different hospital.  I imagine that these kinds of complaints arise in the hospital from time to time.  Furthermore, I was not surprised that these complaints were delivered in such an antagonistic manner, as patients and their families have to deal with a lot of stress while in the hospital. 

However, my shadowing with the team allowed me to look at this situation from the physician’s viewpoint rather than the patient’s.  I was aware of the amount of time and energy that particular physician had given to the patient, as well as all of the other patients under her care.  After getting to know her personality, I truly believed that the physician had a genuine intention to help the patient get better, despite his wife’s opinion.  Thus, it was disappointing to watch her work get criticized in this manner.  The head physician in the team, however, took responsibility and responded to the woman’s claims with a calm tone as she explained that she would be more than willing to discuss these matters with her, one-on-one, after patient rounds were completed. 

When dealing with patients and their families, medical professionals will come across many different kinds of attitudes and personalities, and it is their job to accommodate those differences and stay calm and professional in order to reach an agreement.

I left the hospital and spent the afternoon in VCU’s Ambulatory Care Clinic for the first time, shadowing a pharmacy resident counseling patients in a clinical setting.  Both of the patients who came to the Ambulatory Care Clinic that day were diabetic which, I was told, was commonly seen at the clinic.  The resident informed me that the first patient of the afternoon was one of her most memorable patients because, at his last visit, she was able to convince him to try injecting insulin to lower his blood sugar.  She explained that he had refused at first, but she eventually changed his mind by gradually building trust between the two of them and convincing him that it might be worth trying for the sake of his health. 

She stressed the importance of allowing the patient to decide for himself; it was not the pharmacist’s place to force medical treatments on his or her patients.  She also described the process of teaching the patient how to inject insulin, underscoring the practice of “back-teaching.”  In other words, to ensure that the patient retained the new information, he should be asked to repeat the steps he had learned back to the pharmacist.  This way, it will be clear to the pharmacist whether or not the patient truly understands his instructions.

When the first patient arrived, the resident showed me how she checked blood sugar levels by pricking the patient’s finger and reading the result on the meter.  The monitor read 417, much higher than his ideal blood sugar level, which would have been around 180.  The patient was quite frustrated about not being able to lower his blood sugar despite his insulin injections.  After reviewing all of the patient’s medications, a process that required asking the patient how much and how often each of his medications was taken and checking his responses with his records, the resident determined that all of his medication had been taken correctly.  She then asked the patient to explain to her how he had been injecting his insulin.  After going through the process of “back-teaching” again, she finally determined that the patient had been following the correct procedures.  She ultimately decided to increase the patient’s dosage of insulin.  She asked the patient to describe to her his daily routines, and she suggested a few small lifestyle changes that could be made to help lower his blood sugar, such as adjustments to diet. 

The second patient was not as severely diabetic, so he did not require insulin.  He had come because he wanted to know what each of his medications was treating.  Thus, this visit mostly comprised going over the patient’s medications and explaining their purposes, as well as updating his prescription.  This patient was significantly more knowledgeable in medicine than the first patient, so it was interesting to observe the resident’s change in vocabulary; her explanations became much more thorough and specific.  Afterward, she asked the patient to explain the purpose of each of his medications to her to show that he understood.  That afternoon, I learned that the clinical setting certainly allowed the pharmacist to form a closer relationship with the patient than the busy, fast-paced hospital setting.  Clinics were also less chaotic than hospitals, but the cases seen in the clinic were much tamer than those seen in the hospital.

I returned to the Main Hospital for patient rounds on Sept. 2.  I was no longer shadowing Dr. Gravatt, but I did have the opportunity to go on rounds with another pharmacy resident and a couple of pharmacy students.  I joined a different medical team and spent the first half of the morning conducting “sitting” rounds, as opposed to the “walking” rounds I had previously been doing with Dr. Gravatt.  During sitting rounds, the team congregated in one room and stayed there for the entirety.  The medical students reviewed patient cases while the physicians asked questions and made adjustments as necessary.  Although sitting rounds was much less tiring than walking rounds, which required me to stay on my feet, I felt that it was a comparatively more tedious, and perhaps less thorough, process because it did not provide the team members with direct access of each patient they were reviewing. 

Afterward, the pharmacy resident and the pharmacy students left the other members of the team in order to conduct bedside counseling.  A patient required diabetes training and needed to be taught how to inject insulin, a topic with which I had gained familiarity at the Ambulatory Care Clinic a few days before.  I found that bedside counseling was very similar to the counseling process in the clinic; the only difference was that the pharmacists had to come to the patient instead of the other way around.  Before entering the patient’s room, the resident quickly described the patient’s loquacious nature and affinity to cats so that the students would not begin counseling without some background knowledge of the patient.  With this knowledge, the students were more easily able to connect with the patient, build trust between them, and begin counseling.

“Although I am originally from Wise County, …” COURTNEY HERRON, 7/24/11

Although I am originally from Wise County, this has been my first year attending RAM, and I have to say that it has been an incredible experience. In many ways, I really identify with these patients because I understand how difficult it is to get insurance and find a good job in this area.  It is extremely beautiful and peaceful here, and many people who have lived here their entire lives would never consider leaving. 

However, the remoteness of the area makes it extremely difficult to recruit new businesses, and people here really struggle to find well-paying jobs that offer benefits.  As a result, many are unable to afford going to the dentist or doctor, even if they have been diagnosed with conditions that need to be monitored on a regular basis. Because of this, RAM is extremely helpful in allowing patients to get at least a yearly check-up and have their medications added or adjusted as needed.

My favorite part of this weekend has been getting an opportunity to interact with patients and  apply many of the things that I have learned in the classroom.  I have particularly enjoyed measuring A1C levels in patients with elevated blood glucose readings and counseling patients about medications and disease states. I especially enjoyed counseling patients about diabetes and the A1C test because my grandmother has struggled with the disease for many years. 

While volunteering in this section, I found that several of the patients I encountered did not initially understand why their levels were so high.  However, as I began the conversation about diabetes by asking them questions about their diet, how they were taking their medications and how they often they were testing their blood sugar, the answers soon became obvious. 

One patient I encountered worked as a phlebotomist at a local hospital, but had been without a meter for over a year and so had been unable to accurately adjust her insulin.  Another patient stated that he only ate one meal a day and just “felt bad” when his glucose levels got below 200.  However, once I explained many of the micro- and macrovascular complications of poorly managed diabetes, he was much more receptive to considering a change in diet and working harder to lower his levels.

A second area that I loved working in this weekend was the pharmacy. Again, I enjoyed interacting with patients and counseling them on how to take the medications they had been prescribed and also about the side effects they might experience.  All of the patients I encountered there were so receptive and expressed a level of interest that I rarely encounter at my job in community pharmacy.  In fact, I would go as far to say that I consider those I met to be my ideal patients, and it really drove home the point that sometimes those most interested in their health are unhealthy solely because of lack of education, money and/or opportunity.

All in all, this experience has truly made me appreciate my heritage, and I am so thankful that I got the opportunity to help people that I feel I know and understand and who were so genuinely appreciative of all we did.

“After the amazing experience I had last year …” AMANDA KROLL, 7/23/11

After the amazing experience I had last year at RAM, I couldn’t wait to come back again this year.  I have been eagerly awaiting the opportunity for me to get to know more patients, pharmacists, nurses, doctors and other students as we all work together to serve a common cause.  I was truly humbled last year as I went through the different stations that pharmacy was involved in and got to see how we impact the health of the patients we serve.  

This year, my experience at RAM has been just as wonderful as last year.  So far, the best experiences I have had were while I was using the point of care A1C test.  While getting to use the machine was a great hands-on opportunity, it was also a great time for me to talk to and get to know the patients as well as work on my diabetes counseling skills.  During the five minutes it takes to run the A1C test, I was able to educate patients on how to better manage their diabetes, talk to them about what an A1C test is, how to take their diabetes medications and what to do if their blood sugar gets too low. 

One patient didn’t understand why her blood glucose reading on Friday was in the 300s because when she takes it at home it’s always less than 100.  During the counseling session with her, I discovered that she stores her test strips in the refrigerator.  I was able to talk to her about the importance of storing her test strips at room temperature and how this could cause her to get an error in her glucose readings.  She expressed understanding, and I hope that this will have an impact on the management of her diabetes and insulin. 

While the clinical side of the point-of-care testing was a great learning opportunity, the best part was sitting and listening to the patients.  So many of the patients really enjoy being able to share their story and express their gratitude for the services we provide here at RAM.  To me, this is the most rewarding aspect of RAM.  Knowing that I have in some way made an impact on even just a few patients’ health care is an extremely gratifying feeling.

Reflecting back on these two years I have spent at RAM, I feel really lucky to have been able to be a part of the health care provided.  I am really fortunate to be able to sit with the nurses and learn from them, to be able to listen to the pharmacists and better my counseling skills, and to be able to give back to the community and surrounding areas.  I hope to share my experience with other students and encourage them to come in the future, because I know I will!

“It almost seems surreal to watch …” AMBER LANAE SMITH, 7/25/10, 8:21 a.m.

Location: Triage

It almost seems surreal to watch as nurses, pharmacists  and volunteers begin to tear down the triage area. For the last three days, I have watched as health professionals from all backgrounds worked together for a common goal — something that to me is the epitome of what we all as humans should strive for — love and support of people. This is not my first year at RAM, but it has definitely made my list of top five favorite moments of service.

For me, this trip didn’t start on Thursday morning at 5a.m. —  instead it started the day Adam Krukas handed over his title of team leader (trust me, those were big shoes to fill)! I had visions in my head for where I wanted to expand our team roles and how I wanted to use our team to create an atmosphere that shows pharmacists are an undeniable asset to the health-care world. With a brain full of ideas and an executive board who was willing to work hard, we set out to make this year’s RAM better than any other year (a feat I believe we accomplished)!

Our emphasis as a team this year focused on two vital areas of health care: health education and smoking cessation. In each of these areas, I feel our team excelled and gave the best they could to arm the patients at RAM with tools that could improve their lives. While some efforts were received with open minds and lots of attention (the game), other efforts were harder to approach because they are never easy topics (smoking cessation). But I firmly believe that in each area, at least one patient gained some asset that will help them succeed.

One area that I feel we had the most success in was the A1c clinic. In this part of the triage, the patients had to wait for five minutes to receive their test results. It was during this time that the pharmacy students were able to devote their efforts to direct patient counseling. Several of us spent long periods of time educating patients on the importance of controlling their blood glucose, and we really got to know our patients.

There were a few patients who I talked with at length about their diabetes and their health care in general. Two patients in particular, my “mountain man” and my “veteran,” reinforced my desire to provide everyone with the best service that I can. I saw my “mountain man” all three days, and together we did everything we could to get his blood glucose to drop (a feat we never accomplished — although he still referred to me as his angel from heaven — a nickname I’m not sure I’m worthy of).

The “veteran” was a giant man (not in weight, but in stature) who had kind, old eyes and a heart of gold. I managed to get this patient a world-class treatment on his mouth and some of the best patient care possible. I followed him through the day and checked in multiple times; each time, he had a huge hug for me (and I’d be lying if I said it didn’t make my whole heart soar when he did).

There are two other aspects of RAM that I feel deserve attention, before I finish. The first being the friends you make with other health professionals, especially the nurses. It is amazing to watch as people come together and work so hard from 5 a.m. until 5 p.m. Some people spent the entire day refusing to eat so that more patients could be seen; others rotated through, caring for their teammates they had just met a few hours before starting.

There were three nurses in particular who I felt gave our pharmacy students the best education they possibly could (Vicki, Carol, and Pam). Each of the nurses was excited to impart their years of experience upon our students and made it fun in the process. (Just ask Derek — his nurse made him think she was crazy and danced for her patients)!

But even more amazing than the nurses was our team for RAM this year. Adam said it perfectly when he said that it is amazing that the VCU School of Pharmacy RAM Team is the only student-run organization (with a wonderful preceptor, of course — Dr. Sisson). And in my personal opinion, we did one heck of a job providing the best care we could this year. It has been an absolute honor and privilege to work with each of the students on my team. Every single one of them has touched my heart in a different way, and I will never be the same again.

How can you put into words the impact that service has upon your life? Each year I strive to give all that I have to people, I expect to leave giving everything I have got to improve each person’s life. And yet at the end of the trip, I find that I take more with me than I feel I could have ever given. Not only do I get the opportunity to leave with new friends, I take home stories that make me laugh or cry (or laugh so hard that I cry), things that gross me out  and, above all, I take home a heart overflowing with a desire to love people that much harder and give them that much more of myself. With gifts like that, how could anyone not want to be a part of RAM?!

Look at my life, look at my choices. I think it’s safe to say that anyone who devotes one weekend to RAM made the right choice.