10 tips for getting the most out of fourth year rotations

  1. Take as much as possible out of every rotation, regardless of your future plans.  No one knows for certain what direction a career path will take.  You may not think you will benefit from a particular rotation now, but you never know when some experience or piece of information will be useful to you.  I will most likely never work in retail, yet my community rotation at Guidepoint Pharmacy in Brainerd was one of my best.
  2. Forget the clock.  Preceptors notice which students are counting down to quitting time and which are prioritizing their learning.  If it’s 5:05 pm and a code is called, go with your preceptor to the code.  Don’t miss a good learning opportunity because quitting time was 5 minutes ago.
  3. Interact with other professionals at the rotation site as often as possible.  Some of the best experiences I’ve had on rotations were with physicians or nurses who took me under their wing for a day or an hour and taught me something I could not have learned from a pharmacist.
  4. Say “yes” to requests and opportunities.  If there is a chance to give an extra presentation, do it.  If a physician asks for a consult on a drug list, do it.  If a surgeon asks if you want to pull out a chest tube, do it (that actually happened to me).  You never know what you will learn or the opportunities that may follow when you give that initial “yes”.
  5. Treat the year as one long job interview.  Because the world of pharmacy is so small, it is almost guaranteed that whatever job or residency you apply to in your fourth year, your potential employer will know one of your preceptors and will contact that person for a recommendation.  Your fourth year is like your debut into the world of pharmacy.  It is a huge opportunity to make contacts that could be formative for your career.  It is therefore essential that you make a good first impression and relentlessly protect your reputation.
  6. Forget your grades.  As long as you’re getting good evaluations from your preceptors and making good progress toward graduation, don’t spend any time worrying about your transcript.  No preceptor wants to hear from a student who is upset at receiving a B+ instead of an A.  There is wide variation in the way preceptors grade their students.  Some hardly ever give anything less than an A while others can recall for you the few students who have ever earned A’s from them.  It may not seem fair, and maybe it isn’t, but take the long view.  Those who burn their bridges eventually find themselves trapped on the island.
  7. Turn off your cell phone when you get to the rotation site and don’t turn it on again until you leave or go on break.  Compared to the others this is a somewhat specific piece of advice, but it is meant to highlight a more general principle of professionalism. I’ve heard stories of students texting during a presentation given by the preceptor or playing phone games throughout the day.  I am not going to sugar coat this.  This is completely and unarguably unprofessional.  If it was your job, it would be grounds for termination.
  8. Recognize that you are still a student.   I’ve heard several students say that fourth year is the year you “pay to work.”  To me this implies that coming out of third year we are capable of operating on the level of a pharmacist and that we have little to learn.  In my own case, this could not be further from the truth.  In fact, fourth year was my best learning year yet because daily, hourly, and even by the minute I’ve been challenged by new opportunities to take my book knowledge to the next level and apply it to real situations.
  9. Recognize that you will always be a student.  Fourth year is the year you get to take the helm and still have the captain of the ship to back you up.  This is a remarkable and rare opportunity.  It will never happen again quite the same as is does during the fourth year.  Still, beyond graduation it is essential for your growth and for the safety of your patients that you continue your learning in a deliberate and goal-oriented way.  Continue the mentoring relationships you have already formed and seek out others.  Then become a mentor so that you are challenged to be the teacher.   There is no better way to learn.
  10. Do it for the patient, not the preceptor.  Of course, you should look to your preceptor for guidance, feedback, and learning, but when self-evaluating your performance, the question should be “Am I doing what is right for the patient?” more than “Am I fulfilling the requirements of my preceptor?”  In most situations the first question is a higher standard, and it will be the question you will take with you as you graduate into the profession.
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PD4 papers, Tim Tebow, and why evidence-based scholarship is so difficult

Final PD4 paper drafts were due Dec. 2, and it’s a massive relief to have it finished! Mine is a summary of the research I’ve been doing in the Bauer lab over the last 2 years.  I was planning to have most of the paper done by the end of summer.  However, waiting for the final pieces of data, and hoping to include some results from experiments in September, delayed the process so that I really didn’t get started until mid-October.  In any case, I’ve been working at it feverishly over the last six weeks.  When Dec. 2 arrived and I made the final submission, it felt like emerging from some deep cave into a world of sunshine I had almost forgotten.  Or, like recovering from some long illness that had finally passed. Someone said to me, “We’ve had a beautiful winter so far, haven’t we?” I had nothing to say.  I don’t know.  I haven’t paid any attention at all.

But now I’m back! So, why do we write these papers in the first place? It’s a question I’ve heard asked with wildly varying intonations, indicating everything from sincere inquiry to confrontational suspicion to raging frustration. For those actually seeking an answer, several have been offered. The paper gives each student a chance to probe a specific subject and gain some expertise. It also forces every student to give a presentation to an audience of peers.  Most importantly it teaches the process of appropriately asking a research question, searching the literature, and formulating a complete but concise evidence based answer.  After a couple thousand hours of lab work and a couple months of writing, I now see these answers distilling down to one simple and stark declaration:

If a doctorate level degree is to be earned, then the candidate must provide evidence of the ability to appropriately contribute to knowledge within the field.

Yes, I can hear the tomatoes whistling through the air as I write these words, but there is a fundamental principle at stake here.  Medicine is a system of knowledge based on experimental evidence we use to make recommendations.  When the evidence changes, the recommendations change.  We cannot protect any sacred cows (no offense to my Hindu friends).  It’s not about being right.  It’s about pliability of mind and the willingness to simply follow the evidence. Really, it’s a departure from the way humans generally behave, and it’s not easy to learn.  We are deeply tied to our opinions.  Some love or hate the Vikings (and then hate or love the Packers).  Tim Tebow certainly gets people fired up, for and against.  Everyone seems to have a different favorite sushi restaurant he or she will defend with bared fangs.  And who can deny that U2 is the greatest band in the history of the human race. I’m just throwing that out there.  But really, it’s true. IT IS!!  Dexter is the best show on TV. Or is it Madmen? Or is it Breaking Bad? Or is it Dancing with the Stars? Or is it Antiques Roadshow?  Then there are certain political ideas. If you are a particularly dogmatic adherent to the idea of American exceptionalism, then America is the best at everything simply because it is America.  Of course, we need look no further than average high school math, science, geography, and history scores to see the absurdity in that.

None of these opinions are evidence based, but our defense of them is a reflection of the way we generally operate. We like our evolutionary vestiges of tribalism, or at least we have a hard time escaping them. Our opinions give us identity, so we hang on to them even in the face of contrary evidence. It’s the reason it is so hard to follow the principles of truly evidence-based medicine. Yet we must! The strength and integrity of what we do depends on it. Without the evidence, we are reduced to peddlers of snake oil.

For some, the PD4 paper is the first real experience in shedding the ornamentation of unfounded claims. For all of us it is a test of our ability to sift the data dispassionately and come to a conclusion that is as independent of our personal biases as possible.  In short it is a test of the academic maturity required of a doctor.

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A few tips for selecting fourth year rotations

The third year students have been busy choosing their rotations, and I’ve received some calls and emails from a few of them looking for advice about which rotations I’ve liked the best.  I count myself lucky because I was able to lock in my first choice for six of my rotations and my second choice for two of them.   When I ranked my rotation sites, I followed a few simple rules I thought helped me maximize my chances of getting the rotations I really wanted.  I don’t have any particular knowledge of the computer system that creates the rotation assignments, so take these rules for what they are worth.  And if you follow them, let me know how it goes.

#1  Don’t make 14 selections unless there are eight rotations in addition to the first six that are appealing.  If you will be disappointed receiving a site, don’t put it on the list.  One of my classmates was astonished to be assigned to a site he ranked 12th on his list.  When asked why he selected 12, he said he thought the larger number of selections would give the most flexibility and somehow result in better assignments.  In reality it may have had the opposite effect.  It would make sense that the computer program has been designed to find matches for as many sites as possible.  If only a few students rank a site, every one of those students may be assigned to that site in order to spread students out, thin the number of students who have chosen more popular sites, and give less popular sites their fair share.

#2  Think twice about the block you request off.  Blocks 9 and 7 will likely be the most popular because a block 9 break means you are “done early,” and block 7 is when a lot of students are preparing for residency interviews.  Blocks 6 and 1 are likely the next most popular because they coincide with winter break and the beginning of summer.   If you choose these as your preferred blocks, expect that others will be doing the same.  The result may be stiffer competition for rotation sites in blocks 2,3,4,5, and 8.

#3  There are certain sites that are known to have challenging rotations.  Choose them.  And rank them high.  There may be less competition for those sites because of the reputation.

#4  Place as few geographical constraints on your selections as possible.  It isn’t possible for some students.  For many, it isn’t preferable.  Use that to your advantage.  St. Cloud has some great rotations.  So does Brainerd and Grand Rapids.  If you are a Duluth student, try to open yourself up to rotations in the Twin Cities.  I have four rotations in Duluth, one in Brainerd, two in the Twin Cities, and one in Tanzania.

#5  The final suggestion is less about optimizing your rankings and more about optimizing your job or residency placement.  If you know where you want to practice, or you have a particular residency in mind, try to choose rotations that will put you in contact with people who can make a difference for you.

Good luck to all of the PD3 students with their rotation selections.  I have one more piece of advice for you as you approach your fourth year.  Treat the entire year like one big job interview.  As we have all been warned many times, pharmacy is a small world.  If you are a star, word gets around.  If you are a slacker, word also gets around.  Students who take every opportunity to get out of rotation duty, even if it is with the permission of the preceptor, are at best forgettable, and at worst, memorable for the wrong reasons.  Instead, take control of your learning and see that fourth year can be the one in which you make the greatest strides in your knowledge.  Fourth year allows you to explore as far as you are willing to roam.  It’s your chance to sit in the captain’s seat and still have the captain there to back you up.  It can be the best year of your education, but that will be up to you.  Don’t waste it.



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PD4s Reach the Half-way Point!

At lunch today we passed the midpoint of the year.  That tiny point of light that has been off in the distance for so long has now become a spot of recognizable daylight.  And it grows daily.  We will be crossing that stage before we know it.  Congratulations to the class of 2012!

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Serotonin Syndrome and Linezolid

On rotation recently I had a discussion with my preceptor about serotonin syndrome resulting from concurrent use of serotonergic antidepressants (SSRIs and SNRIs) and monoamine oxidase inhibitors (MAOIs).  As a class of antidepressants, MAOIs have fallen out of favor, but some patients have used them for years with success and continue to take them.  A few are still available in the US, including phenylzine (Nardil®), tranycypromine (Parnate®), and Isocarboxazid (Marplan®).

Last week I saw two patients on the same day who were both taking phenylzine.  It prompted our discussion of serotonin syndrome, which then led to the comment that linezolid (Zyvox®) has MAOI properties and should be used with caution in patients on SSRIs and SNRIs.  Linezolid is a powerful antibiotic used for vancomycin resistant E. faecium (VRE) infections, community acquired and nosocomial pneumonias due to MRSA and multi-drug resistant Strep pneumoniae (MDRSP), and skin and skin structure infections (SSSIs) caused by susceptible gram positive organisms.  Linezolid is one of our big guns against the gram positive heavy weights.

Coincidentally, the FDA has just issued an update to a previous warning about the use of linezolid (Zyvox®) with SSRIs and SNRIs.  They state, “Most cases from the FDA’s Adverse Event Reporting System (AERS) of serotonin syndrome with linezolid occurred in patients taking specific serotonergic psychiatric drugs.”  As a general rule, “most serotonergic psychiatric drugs should be stopped at least 2 weeks in advance of linezolid treatment. Fluoxetine (Prozac®), which has a longer half-life compared to similar drugs, should be stopped at least 5 weeks in advance.”  In emergency situations “requiring life-threatening or urgent treatment with linezolid, the availability of alternative interventions should be considered and the benefit of linezolid treatment should be weighed against the risk of serotonin toxicity.”

Medpage Today covered the FDA announcement in an article published last Friday.

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Diving…in Brainerd?!

Before leaving Brainerd to return to Duluth for my block 5 rotation I went diving with Jason, one of the GuidePoint pharmacists, in the Cuyuna Recreation Area.  Several lakes now fill abandoned mining pits left over from the iron mining heyday, which built several of the surrounding towns, including Crosby-Ironton and Cuyuna.  The pits have been inactive for more than 30 years, and now the recreation area has some of the best mountain biking and freshwater diving in the country.  On this dive we followed the old road down the side of the pit, hugging the edge of a wall that dropped to well over a hundred feet, looking at old trees still rooted in place as well as some left over mining equipment.   One highlight was a school of curious bluegill that surrounded us, swimming to within inches to get a close look the strange black creatures visiting their home.  One swam right up to my mask and hovered for a couple minutes, seemingly friendly but hopelessly puzzled by my presence.  We also saw a huge northern hiding in the weeds on the bottom.  He wasn’t quite as big around as my tank, but close.  I didn’t notice him until I was within a couple feet, and I lost the air in my lungs as he jerked himself off the bottom in a cloud of silt, darting off into the blue.

The Minnesota School of Diving is located in downtown Brainerd, right next to the old watertower.  I brought my regulator in before the dive because I thought it was leaking.  Before I even finished my sentence, the owner said, “Don’t worry.  Your regulator is fine.  It has a pressure release valve.”  Good, honest people, I like that.  I’m going to need a new BCD next year and I think I’ll make a special trip to buy it from them.  See their website at http://www.mndiving.com/main_frm.htm.

Also check out the Cuyuna Recreation Area website at http://www.dnr.state.mn.us/state_parks/cuyuna_country/index.html.

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Thank you, GuidePoint!

Friday was the last day of block 4 rotations, and it is only reluctantly that I leave my community rotation at GuidePoint Pharmacy in Brainerd.  Five weeks ago I might have found this reluctance somewhat surprising, leaning as I do toward a career in the hospital.  But after working with Laurie and Mike Schwartzwald, and with the staff of GuidePoint over the last month, I would have gladly stayed for as long as they would have kept me.

The first and most important thing to say about GuidePoint is they are truly patient focused.  They make a point of staffing heavy, so they have the time to give every patient individualized attention.  On numerous occasions I’ve seen Laurie spend 20 minutes with a patient.  I’ve also heard several patients say they get their flu shots at GuidePoint because the pharmacists take extra time to make patients feel comfortable.

The added staffing also ensures they have suffcient time to spend with their students.  Laurie and Mike take 15-20 students per year, and they make a concerted effort to tailor the rotation to meet their students’ needs and goals.  I wanted to focus on two things: vaccinations and counseling points for common medications in the community setting.  When I wasn’t out helping with flu clinics, Laurie frequently spent the majority of her day with me reviewing disease states and therapy.  We often had long and wide ranging discussions about the basic physiology and pharmacology.  My learning was definitely a priority, and she always had time for me.

The same can be said of the other pharmacists and staff at GuidePoint.  Everyone was available, patient, and willing to teach – and they made a point to challenge me.   They’d say, “I need a pharmacist,” and then hand me the phone or the new med consult.  The hot seat wasn’t so comfortable at first, but over the five-week rotation, I gained a new confidence and even enjoyed the responsibility, especially when I was able to make a real difference for a patient.

I want to thank Laurie, Mike, and everyone else at GuidePoint for a phenomenal five weeks.  Anytime I can be of service, you’ll find me back in Brainerd (and I’ll bring the lemon angel pie).

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