Early APPE advice

ON ROTATION

By Leah Stowers, PharmD, MPH

Wow, “Ami,” it sounds like you had quite a humbling experience, and just at the start of rotations. I know it can be terrifying to be on a new rotation as a student pharmacist, especially in an unfamiliar setting. Often you are given very little guidance as you begin patient care in a new setting. Some preceptors are more apt to give you detailed instructions while others hope you will pick up the day-to-day expectations on your own.

As a student, it is very easy to observe the actions of your preceptor and mimic them, but if every student pharmacist only mimicked their preceptors, innovation in pharmacy practice would be limited. The pharmacist’s role on the health care team has expanded tremendously in recent years not due to imitated behavior, but rather to pharmacy innovators. I wish I had been in the room during the first conversation where a pharmacist provided an antibiotic recommendation or when a pharmacist noticed a high serum creatinine on a patient and suggested a dose adjustment to the team. 

As you develop confidence in your knowledge, you will start to develop ideas of how you can help your patients and discuss those areas with your preceptor.  

Your code room experience

In the code room, I am sure you now identify the critical roles in that patient’s care. Maybe you will start to document the time of each administered therapy, proactively calculate a dose, or have the anticipated medication ready to administer. Your preceptor may not have explicitly stated their actions during the code; their preparation of the epinephrine push was a gap they filled, anticipating the needs of the team. You might start by familiarizing yourself with the location of items in the crash cart or study cases for specific medications to administer in code situations. Over time, your relationship with the team and the confidence in each discipline’s abilities and contributions will grow.

Patient loss is something school could never prepare you for. Health providers are trained to preserve life, and therefore rarely discuss dealing with the loss of a patient. Providing comfort and compassion is something that cannot be taught, but is often welcome and needed by family and friends. Observation of other providers can offer insight into appropriate interactions with grieving families, and if still unsure, consult your preceptor for advice. 

Always be prepared

You will notice that each patient encounter may not be as critical as a code room, but your knowledge as a student pharmacist can make a significant impact on a patient’s health. My philosophy during rotations was always to be prepared to discuss each patient as if they were my only patient. Preparation is crucial; you may notice something critical that everyone else overlooked.

I vividly remember a rotation I had in the ICU. Each day our preceptor would discuss our assigned patients before rounding with the rest of the team. She quizzed us on critical labs and medication-related problems she had noticed during her workup. On multiple occasions I was stumped because she had never asked us about that specific lab, and I didn’t realize the importance of the pharmacist to monitor. The next day, I would make sure I looked up that specific lab on each patient and was prepared to discuss it along with each of the other critical labs.  

As prepared as I felt, she quizzed me on another problem we had never discussed. The cycle continued throughout the rotation. I realized by the end of the rotation I knew each patient thoroughly by developing a routine to review each critical lab, monitoring parameter, medication, etc. While I didn’t need to discuss each lab daily, I created a system to review every component of each patient. My preceptor had strategically trained me to monitor every crucial lab and how they played a role in patient management.  
 

The trust will come

While each of your rotations won’t involve this type of patient evaluation, what you will be doing is caring for patients, and this model can be applied to any area of pharmacy practice. Know your patients, their medications, their comorbidities, and any labs you have access to. Make sure to always discuss recommendations with your preceptor and ask for feedback. Providing thoughtful suggestions without being overly assertive will help to establish trust over time with your health care team.

Your preceptors can share insight on ways they have demonstrated professional value on their own teams. With time, you will develop a relationship with other providers and making 
recommendations will become more comfortable. I wish you the best on 
rotations and in your future career!