Help Me to Help Them

[Dr JPH]

I currently have 2 pharmacy students rotating on an inpatient internal medicine service. Im looking for ideas on topics, presentations, discussions, etc that will maximize their education while also educating my medical students.

Thanks

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[Requiem]

I currently have 2 pharmacy students rotating on an inpatient internal medicine service. Im looking for ideas on topics, presentations, discussions, etc that will maximize their education while also educating my medical students.

Thanks

If you're a surgery resident, do up a presentation with "top 15 most used meds" in general [or whatever] surgery - with Reasons why, mechanisms of action, side effects, potential toxicities, what to monitor post administration.

Presentation on the importance of medication reconciliation - that is obtaining accurate medication info prior to their admission: what meds they were on, accurate dosages etc and then implementing that into pharmaceutical care with regards to inpatient meds, surgery prophylaxis, discharge meds, etc.

Do presentations on how meds they found out patient X was on would have resulted in Drug Related Problem Y had pharmaceutical care not been implemented.

Let the pharmacy students push their drug pharmacology/knowledge, let the med students push their pathology/dx knowledge, you should get some good presentations.

 

[KARM12]

I currently have 2 pharmacy students rotating on an inpatient internal medicine service. Im looking for ideas on topics, presentations, discussions, etc that will maximize their education while also educating my medical students.

Thanks

Have them present short inservices on new drugs or give them drug information questions. If there is a particular area you work in...have them make a reference card that the physicians can use with the most commonly used drugs, doses, monitoring parameters, etc

 

[npage148]

I had to give one on the management of hyperthyroidism. I was not really exposed to it in school so it was good learning and the residents were also interested.

Drug induced Hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP)

Oral verus IV N-acetylcysteine for APAP toxicity

 

[njac]

I was the only pharmacy person on an emergency surgery service a couple weeks ago. One thing I did was follow up on patient home meds - lots of po psych meds were stopped and the pt could've been npo (except for meds) but instead they were npo for about 10 days at that point.

I was impressed to see surgeons writing for more than "Ancef 2g q8h x3"

 

[Dr JPH]

Thanks for the ideas, keep them coming!

Next week they are going to be helping the medical students (and myself ) gain a better understanding of the different inhalers, nebulized meds and oral drugs that we place patients on in the hospital for respiratory compromise.

One of the biggest challenges is looking up all the inhalers...I know what classes of drugs I want my patient on, but I dont know which brand name contains them!

This past week they presented all of the anticoagulants from Aggrenox to Lovenox. They did a great job. They were able to go over all the dosing schedules and mechanisms while we were able to help them better understand all of the pathology we would use these drugs in.

 

[Mags]

I was just about to say "Anticoag!!!". When to stop start/before surgery and why (half life), what to do post surgery, etc

What about antibiotics? I know from my clinical rotations 4th year that there were a lot of pre treat/post treat prophylatic antibiotics. Antibiotic reviews (class/bugs covered, which cover pseudomonas, which penetrate CNS) are always good b/c things are usually always changing in that field.

Or how about certain things done in surgery? For example when I was on cards and we had some patients transfer to CT surg, the surg team didnt want ACE Inhibitors on board 24 h prior b/c for some reason they said it made it harder for the patient to come off pressors afterwards? I may be wrong on that, but it was a surgery specific treatment/therapy I had never heard of just b/c I had never been exposed to it.

Pressors/vasodilators are probably a good topic as well (depending on your use in your particular facility)

 

[sdn1977]

I was going to suggest bronchodilators & the use of inhaled steroids - good job!

Other topics for acute internal medicine:

-pain management - from the standard anxiety related headache to the pt who comes in on oxycontin/fentanyl patch & needs to be converted over to IV medication for pre-op/post-op or how to cover current addiction while tx normal pain associated with medical procedures. (btw....don't even talk about propoxyphene - its being discussed being removed from the market in a few years...).

-antibiotics - who gets them, whats on the forumulary, first choice, second choice, third choice - why, what are the considerations you use in choosing (ie place of potential infection, penetration, "costs" associated - lab work with some & not with others), how do you proceed when someone says they're allergic to pcn, sulfa & cipro (teaches both medical & pharmacy students how to elucidate an allergy from an adverse reaction during hx taking).

-GI prophylaxis - does everyone need it??? Is there a difference between that 80 yo stroke w hx COPD, s/p hip replacement, htn, CAD, etc.... & the hernia repair on a 28 yo male with no significant medical hx. What is the difference between histamine blockers & PPIs - both pharmacologically & economically. What are the economics of using a "standard" drug like this routinely in a hospital (think how many pt days there are & relate that to cost).

-the use of crystalloids vs colloids - when do you use what & why. How do you calculate fluid requirements. How do you evaluate those lab numbers & put them in perspective WITHIN the context of the pt at the time (ie...the number may be appropriate post-op, but wouldn't if it was an admit off the street). You could extend this into nutritional support if you have that much on your service, but that may be more than what you want to do.

-then there is our (& the nurses favorite).....bowel maintenance. What is the course of progression from stool softener, fiber, laxative to more aggressive measures if long term bedrest & opioids are present. Not a big pharmacologic issue, but if you can prevent a GI consult because of "forgetting" about this - its a good thing.

Good luck!

 

[Dr JPH]

I was going to suggest bronchodilators & the use of inhaled steroids - good job!

Other topics for acute internal medicine:

-pain management - from the standard anxiety related headache to the pt who comes in on oxycontin/fentanyl patch & needs to be converted over to IV medication for pre-op/post-op or how to cover current addiction while tx normal pain associated with medical procedures. (btw....don't even talk about propoxyphene - its being discussed being removed from the market in a few years...).

Pain management is always a hot topic. Understanding half lives, receptors, etc.

-antibiotics - who gets them, whats on the forumulary, first choice, second choice, third choice - why, what are the considerations you use in choosing (ie place of potential infection, penetration, "costs" associated - lab work with some & not with others), how do you proceed when someone says they're allergic to pcn, sulfa & cipro (teaches both medical & pharmacy students how to elucidate an allergy from an adverse reaction during hx taking).

Another hot topic. What bugs to cover, duration of Abx course.

-GI prophylaxis - does everyone need it??? Is there a difference between that 80 yo stroke w hx COPD, s/p hip replacement, htn, CAD, etc.... & the hernia repair on a 28 yo male with no significant medical hx. What is the difference between histamine blockers & PPIs - both pharmacologically & economically. What are the economics of using a "standard" drug like this routinely in a hospital (think how many pt days there are & relate that to cost).

There are some interesting papers on PPI use and ventilator associated pneumonia.

-the use of crystalloids vs colloids - when do you use what & why. How do you calculate fluid requirements. How do you evaluate those lab numbers & put them in perspective WITHIN the context of the pt at the time (ie...the number may be appropriate post-op, but wouldn't if it was an admit off the street). You could extend this into nutritional support if you have that much on your service, but that may be more than what you want to do.

-then there is our (& the nurses favorite).....bowel maintenance. What is the course of progression from stool softener, fiber, laxative to more aggressive measures if long term bedrest & opioids are present. Not a big pharmacologic issue, but if you can prevent a GI consult because of "forgetting" about this - its a good thing.

Most surgeons are militant on these two topics. They have their own thoughts and methods, and often you cant change their minds about what the best regimen, best fluid, best rate, best tube feed, etc! Might be better to stay away from these!

Good luck!

Thanks for the ideas.

 

[tussionex]

i like crystalloids vs colloids....a hot topic at our hospital right now. it's hard to believe that a little bag of fluid can cause so much debate. it's also good for the pharmacy student to understand how these fluids work....it's definately not something they see in school but will see every day...

 

[sdn1977]

JPH - you must, of course, choose your own method of teaching...but, personally, I prefer those topics in which you can't change attending minds to have students use as topics for teaching. Not to change those attendings minds (& certainly not to provoke controversy), but to help the students understand why the attending has made that personal choice.

Altho, we can all go back to the most recent papers covering bugs, drugs, receptors & inhibitors...sometimes your medical students might not really learn WHY they use something as common as fluids & certainly, as Tussionex pointed out - most pharmacy students don't know why some fluids are used & unless the pharmacist is out in patient care areas, might never know.

There is usefulness in knowing what D5LR v NS v 0.45% NaCl v albumin will do to all the fluid spaces in different scenarios - trauma, post-op, dehydration, etc..certainly as a pharmacist in the ER, OR or ICU - its expected we anticipate as well as respond.

Now - there is also usefulness in knowing Dr XYZ prefers this & Dr PDQ perfers that (pharmacists learn that early). But, learning that there is more than one right way to "skin a cat", so to speak, is itself useful and knowing that the physiology can be corrected many ways is beneficial & can reinforce the attendings reasoning while providing knowledge of reasons behind other methods.

If done well - by choosing your student carefully - it could be a great discussion & learning session. If done poorly - yep - better to stay away - could cause too much controversy & problems for you.

I've had MSIII home for a few days & she's come so far, but still has some knowledge gaps when I ask her the WHY of something she's done or observed (she just finished acute internal medicine). She got so much information so fast. Repetition is a good teacher, which medicine provides far better than pharmacy.

So - getting both your sets of students who come from different perspectives to understand a medical or physiological process, procedure or treatment is HUGE undertaking & you're to be admired that you consider what each can teach & learn from the other.

Again - good job & good luck! I hope its a enjoyable undertaking for you as well.

 

[tussionex]

and, were i a student...i would completely enjoy doing a rotation with med students. it would be fun to explain the drugs to the med students as well as let them explain how the body works. sometimes, the best way to learn something is to have to teach it to someone else. that's why, now, i love having students around. keeps me on my toes!

 

[sdn1977]

and, were i a student...i would completely enjoy doing a rotation with med students. it would be fun to explain the drugs to the med students as well as let them explain how the body works. sometimes, the best way to learn something is to have to teach it to someone else. that's why, now, i love having students around. keeps me on my toes!

Weren't you with med students as a pharmacy student???

 

[tussionex]

nope.
acp is a small, isolated little pharmacy island. we used to study [and eat] across the street at albany med, but never had specific, didactic anything with the med students.
i did my rotations at a VA and a small, non-teaching hospital. so, nope, no med students there either.

we've been getting a fair amount of pharmacy students at my hospital. we have even had a 4th year student working as a tech/intern all summer. it's fun...i like to ask them weirdo questions. sometimes i stump myself

 

[Dr JPH]

2 new pharm students coming tomorrow...time for a change anyway.

Things ended sorely with the last pair...one of them tried pimping me on rounds the other day.

Wasnt recieved well by the team.

 

[SpirivaSunrise]

Things ended sorely with the last pair...one of them tried pimping me on rounds the other day.

Wasnt recieved well by the team.

What???

 

[Dr JPH]

What???

 

[Epic]

Selective alpha 2 adrenergic agonist vs alkylphenol in procedural sedation.

Should be an interesting topic.

 

[Dr JPH]

What???

true

 

[sdn1977]

2 new pharm students coming tomorrow...time for a change anyway.

Things ended sorely with the last pair...one of them tried pimping me on rounds the other day.

Wasnt recieved well by the team.

Too bad - not a good thing. As I said, its a fine line to walk, particularly when you don't have a pharmacist "attending" or staff person on your team who can give the pharmacy students some guidance on when & how to ask questions or promote discussion.

This is an absence in pharmacy education when you don't attend school with med students & nursing students (or PA, NP's, etc..) as in Tussionex's experience.


There is some learning in how to develop communication techniques with other professions, which should have gone on before they ever get to you. Its unfortunate that you were presented with such a difficult pair & I hope the next ones are better for you.

For those who must choose on pharmacy schools - this is why multidisciplanary schools can be beneficial rather than those which are free-standing without "official" guidance in defined clinical activities which interact with otherr professions. It just gives you a broader perspective.

Good luck with the next set - you are again to be commended for your willingness to engage & help expand their education.

Good luck!

 

[Dr JPH]

For those who must choose on pharmacy schools - this is why multidisciplanary schools can be beneficial rather than those which are free-standing without "official" guidance in defined clinical activities which interact with otherr professions. It just gives you a broader perspective.

Agreed.

Good luck with the next set - you are again to be commended for your willingness to engage & help expand their education.

Good luck!

Im married to a pharmacist...I see her knowledge base and I want to make sure those coming after her can reach the same level.

 

[tussionex]

dr JPH...sorry that you had some difficult students.

i always felt, and try to remind our current students, that you are a guest in someone else's "house" and to act accordingly.

it's great that you want to encourage the pharmacy students as well as your own med students. good luck!

 

[Requiem]

true

haha mind sharing how the conversation went down?

I'd like to hear the question/your response.

 

[Dr JPH]

haha mind sharing how the conversation went down?

I'd like to hear the question/your response.

She basically asked me a drug of choice question on a completely unrelated topic than what we were discussing on rounds. Seemed pretty random to me, plus she was staring at her Palm at the same time.

I have students ask questions all the time, including her. But this was different...just the manner and tone. Almost like a "I bet you dont know the answer to THIS" type question.

Another resident and a 4th year med student looked at me, then at her. The Pharm student looked at us like "I asked a question, why arent you answering me".

The other resident almost lost it...she walked away...I followed. The 4th year medical student tried to explain the etiquette about such things...NOT pimping anyone at or above your level...or if youre a student, not pimping anyone at all. The pharm student went off about how "we are all on the same level" and that she can "ask anything she wants to anyone she wants."

It was quite a scene on rounds. Luckily the chief resident and attending were in the patients room when this all took place in the hallway. I tried to diffuse the situation but it was pretty crazy. Later I tried to talk to her and explain that YES we were all students in some capacity...all still learning...but that we were not on the same level and that indeed there was a clearly marked hierarchy. She didnt want to hear anything of it.

This was all a week after the same student told the Chief of Cardiology that he was wrong about Digoxin during morning conference.

 

[tussionex]

wow.

if that were my student, i would be opening up the can off whoop-a$$. probably in the form of some mind numbing, time consuming, incredibly detailed DUE's.
confidence is great, and so is the spirit of interdisciplinary rounds...but c'mon, let's be real...there is a pecking order.
and, if you're a student, you tend to be at the bottom. you're there to be pimped, not do the pimping.

 

[Epic]

She basically asked me a drug of choice question on a completely unrelated topic than what we were discussing on rounds.

What was the question?

 

[Dr JPH]

What was the question?

"What is the drug of choice for GERD in a pregnant woman?"

Asked by a Pharmacy student to a Surgical Intern on Medicine Rounds in a hospital that doesnt have an OB service.

 

[Epic]

"What is the drug of choice for GERD in a pregnant woman?"

Asked by a Pharmacy student to a Surgical Intern on Medicine Rounds in a hospital that doesnt have an OB service.

That's a great question. Of course at an inappropriate time and place.

I would've just said..."hell...I don't know...why don't you find out and give us a presentation on it..." and be done with it. And that's because I don't have the answer in front of me.

Then again, if I had the answer, I would have blurted it out...and moved on.

 

[Dr JPH]

That's a great question. Of course at an inappropriate time and place.

I would've just said..."hell...I don't know...why don't you find out and give us a presentation on it..." and be done with it." And that's because I don't have the answer in front of me.

Then again, if I had the answer, then I would have blurted it out...and moved on.

I thought it was a good opportunity to help the young lady understand the dynamic of an interdisciplinary team...especially one with students and residents at a teaching hospital...so I chose that route.

 

[npage148]

Man, Doctors are a touchy bunch. A student was mildly inappropriate and the hospital almost exploded in chaos.

 

[sdn1977]

I thought it was a good opportunity to help the young lady understand the dynamic of an interdisciplinary team...especially one with students and residents at a teaching hospital...so I chose that route.

I admire your patience!

Depending on the time of day, #s of pts to be followed, how heavy the load was....I perhaps might not have been as patient.

I must ask though - where was her supervising rx & why didn't that person step up & fill the young lady in?

Then....to counter an attending on any drug within that individual's service - gosh....she didn't have a clue, did she?????

 

[Dr JPH]

Man, Doctors are a touchy bunch. A student was mildly inappropriate and the hospital almost exploded in chaos.

Mildly inappropriate? 6th year PharmD student pimping physicians on teaching rounds.

I admire your patience!

Depending on the time of day, #s of pts to be followed, how heavy the load was....I perhaps might not have been as patient.

I must ask though - where was her supervising rx & why didn't that person step up & fill the young lady in?

Then....to counter an attending on any drug within that individual's service - gosh....she didn't have a clue, did she?????

Unfortunately there is no clinical pharmacist who makes rounds with us. The student threatened to "tell her preceptor" about the incident but we never heard anything from him.

You just dont tell attendings theyre wrong. It doesnt work like that. ESPECIALLY the chief of cardiology who has been practicing for more than 20 years. I dont care if he says "Digoxin is best given rectally in a peanut butter emulsion." You nod your damn head and pretend to take notes.

 

[sdn1977]

Mildly inappropriate? 6th year PharmD student pimping physicians on teaching rounds.





Unfortunately there is no clinical pharmacist who makes rounds with us. The student threatened to "tell her preceptor" about the incident but we never heard anything from him.

You just dont tell attendings theyre wrong. It doesnt work like that. ESPECIALLY the chief of cardiology who has been practicing for more than 20 years. I dont care if he says "Digoxin is best given rectally in a peanut butter emulsion." You nod your damn head and pretend to take notes.

Yep, so true. Now, Zpak might have given the guy grief & I've seen my dop argue an attending down (no, no - it should be given in soy milk enemas...) - but, those have never, ever been in public places & never, ever in front of students & staff.

I'm guessing you never heard from the preceptor 'cause the preceptor told her she was inappropriate. This incident would make me want to have a meet with the preceptor before another set of students rolls thru - they need some basic hospital etiqutte taught before they come on your service.

 

[Dr JPH]

I'm guessing you never heard from the preceptor 'cause the preceptor told her she was inappropriate.

Probably

This incident would make me want to have a meet with the preceptor before another set of students rolls thru - they need some basic hospital etiqutte taught before they come on your service.

The 2 new students are very nice. Quiet & shy so I had a talk with them yesterday to encourage them to look at charts, ask questions when they dont understand something and try to become involved in rounds.

As I said above, I see how educated my wife is (she is a PharmD) and I want these kids to become the same way.

 

[npage148]

Mildly inappropriate? 6th year PharmD student pimping physicians on teaching rounds.

Sorry, I did not see your on your pedestal.

You just dont tell attendings theyre wrong. It doesnt work like that. ESPECIALLY the chief of cardiology who has been practicing for more than 20 years. I dont care if he says "Digoxin is best given rectally in a peanut butter emulsion." You nod your damn head and pretend to take notes.

Why not? If they are wrong, they are wrong and need to be called out. He'll just keep going on like he's an infallible god who never waivers. Seriously, this whole doctor hierarchy is unnecessary and a detriment

 

[Dr JPH]

Sorry, I did not see your on your pedestal.

Up here!

Why not? If they are wrong, they are wrong and need to be called out. He'll just keep going on like he's an infallible god who never waivers.

#1 He wasnt wrong, the student was wrong.

#2 It is never appropriate for a student to call out a professor during a lecture.

Seriously, this whole doctor hierarchy is unnecessary and a detriment

I disagree. When you bear the ultimate responsibility (especially in the eyes of the judicial system) then I think being a bit controlling about those under you is justified.

 

[acetyl]

 

[Dr JPH]

I dont know why this would turn into a circus.

I never stepped on the pharmacy profession.

I never said one negative thing.

Yet somehow, someone is going to turn what I said around and make it seem so.

All I said was "a pharmacy student was pimping physicians."

If anyone can justify that and consider it appropriate then you have a misguided view IMO.

I would have said the same thing if it were one of my medical students, a nursing student or otherwise.

It just should not be done. You are a student and you are there to learn, not challenge the knowledge of those above you by quizzing them on medicine rounds.

So go ahead...begin your "Dr JPH hates pharmacists" bullcrap. Ive heard it before...though this is probably one of the only times I dont deserve it.

 

[tussionex]

heirarchy creates order. it may be demeaning to those lower in rank...but it does serve a purpose far greater than the egos of those being ranked ie, the military.

students do need to know their place. i wouldnt be rude about it, just firm.

 

[Caverject]

Sorry, I did not see your on your pedestal.



Why not? If they are wrong, they are wrong and need to be called out. He'll just keep going on like he's an infallible god who never waivers. Seriously, this whole doctor hierarchy is unnecessary and a detriment

Good God...you should be an interesting one when you hit rotations...

there is a thing called etiquette and this student JPH described had none of it. It's ridiculous that the student (and you) didn't know any better.

 

[Dr JPH]

heirarchy creates order. it may be demeaning to those lower in rank...but it does serve a purpose far greater than the egos of those being ranked ie, the military.

students do need to know their place. i wouldnt be rude about it, just firm.

And I think I handled the situation pretty well. I didnt embarrass her or call her out. I tried to keep it quiet but she was the one who lost her temper.

Good God...you should be an interesting one when you hit rotations...

Maybe I should give him this girls number?

there is a thing called etiquette and this student JPH described had none of it. It's ridiculous that the student (and you) didn't know any better.

 

[Cocogirl]

I've had MSIII home for a few days & she's come so far, but still has some knowledge gaps when I ask her the WHY of something she's done or observed (she just finished acute internal medicine). She got so much information so fast. Repetition is a good teacher, which medicine provides far better than pharmacy.

SDN - why do you think medicine is better at providing repetition than pharmacy? Do you think the same is true for pharmacists working in specialty areas?

Just curious!

 

[Epic]

Yep, so true. Now, Zpak might have given the guy grief & I've seen my dop argue an attending down (no, no - it should be given in soy milk enemas...) - but, those have never, ever been in public places & never, ever in front of students & staff.

I'm guessing you never heard from the preceptor 'cause the preceptor told her she was inappropriate. This incident would make me want to have a meet with the preceptor before another set of students rolls thru - they need some basic hospital etiqutte taught before they come on your service.

Zpack gives many attendings painful grief. That's his job. It takes place not in public...but in closed door meetings. Those attendings that do not receive grief are those who can clinically and financially justify their prescribing habit. Preservation of financial solvency of a hospital is a responsibility of everyone in order to provide needed care to patients.

 

[no-see-um]

Perhaps also they should learn what medications NOT to take before surgery and when to d/c them.