INTERNAL MEDICINE AND OTHER CLINICAL ROTATIONS

Mate M. Soric, PharmD, BCPS

CASE

J.B. is a pharmacy student starting his internal medicine APPE rotation. His preceptor has asked him to begin “working up” the patients on the floor so that he will be prepared for rounds later that morning. J.B. reads through the chart that belongs to the first patient on the list, a 61-year-old man admitted with a congestive heart failure exacerbation. The patient’s case is complex, so the medical record is quite large and J.B. spends a great deal of time digging through the various sections looking for important information. Not helping matters, J.B. is repeatedly referring to resources on a desktop computer to help him decipher the various diagnostic tests and evaluate the patient’s drug therapy. As a result of the large amount of time spent working up the first case, J.B. is unable to review all of the patients on the list before reporting to his preceptor.

WHY IT’S ESSENTIAL

The internal medicine and specialty APPEs (often called clinical rotations) play an important role in the development of critical thinking skills and drug information knowledge for pharmacy students. Regardless of the career goal you have in mind, the ability to evaluate a patient’s medical information, identify drug therapy problems, design therapeutic interventions, and communicate recommendations to other healthcare providers are invaluable skills that must be mastered. Few other rotation types allow for the application of these skills on a daily basis.

ARRIVING PREPARED

• Contact the preceptor before the rotation begins for clarification on any required readings, disease states to review, and logistical information (parking, arrival time, etc.).
  
• Review the rotation syllabus.
  
• Wear professional dress, including white coat.
  
• Bring the following items:
  
•   Calculator
  
•   Pocket reference guides (Drug Information Handbook, Pocket Pharmacopoeia, Sanford Guide, etc.) or their electronic counterparts
  
•   Clipboard or folder
  
•   A patient monitoring sheet
  
• Review pertinent class notes:
  
•   Types of drug-related problems
  
•   Presentation skills
  
•   Patient interview and counseling skills
  
•   Evaluation of drug literature and statistics
  
• Common disease states to review:
  
•   Internal medicine rotations:
  
•   Acute coronary syndromes
  
•   Atrial fibrillation
  
•   Congestive heart failure
  
•   Stroke
  
•   Hypertension
  
•   Thromboembolic diseases
  
•   Anemias
  
•   Chronic obstructive pulmonary disease
  
•   Asthma
  
•   Diabetes
  
•   Cirrhosis and hepatitis
  
•   Pancreatitis
  
•   Pain management
  
•   Pneumonia
  
•   Skin and soft-tissue infections
  
•   Urinary tract infections
  
•   Cardiology rotations:
  
•   Hypertension
  
•   Angina pectoris
  
•   Myocardial infarctions
  
•   Atrial fibrillation and flutter
  
•   Paroxysmal supraventricular tachycardia
  
•   Ventricular arrhythmias
  
•   Torsades de pointes
  
•   Atrioventricular and bundle branch blocks
  
•   Pericarditis
  
•   Systolic and diastolic heart failure
  
•   Hyperlipidemia
  
•   Valvular diseases
  
•   Syncope
  
•   Cardiomyopathies
  
•   Infectious disease rotations:
  
•   Complicated skin and soft-tissue infections
  
•   Diabetic foot infections
  
•   Pyelonephritis
  
•   Community-, healthcare-, and ventilator-associated pneumonia
  
•   Influenza
  
•   Tuberculosis
  
•   Infective endocarditis
  
•   Clostridium difficile colitis
  
•   Osteomyelitis and infected prostheses
  
•   Human immunodeficiency virus infections
  
•   Bacterial and viral meningitis
  
•   Invasive fungal infections
  
•   Parasitic infections
  
•   Sexually transmitted diseases
  
•   Intensive care unit rotations:
  
•   Sedation and pain management
  
•   Fluid and electrolyte disturbances
  
•   Acute renal failure
  
•   Acid–base disorders
  
•   Stress ulcer prophylaxis
  
•   Delirium
  
•   Septic, hypovolemic cardiogenic, and anaphylactic shock
  
•   Acute respiratory distress syndrome and ventilator management
  
•   Diabetic ketoacidosis
  
•   Hypertensive urgencies and emergencies
  
•   Acute coronary syndromes
  
•   Ventricular arrhythmias
  
•   Status epilepticus
  
•   Status asthmaticus
  
•   Psychiatry rotations:
  
•   Depression
  
•   Anxiety and panic disorders
  
•   Bipolar disorder
  
•   Schizophrenia
  
•   Personality disorders
  
•   Alzheimer’s and vascular dementia
  
•   Delirium
  
•   Obsessive-compulsive disorder
  
•   Post-traumatic stress disorder
  
•   Sleep disorders
  
•   Oncology rotations:
  
•   Breast cancer
  
•   Gynecologic malignancies
  
•   Prostate cancer
  
•   Testicular cancer
  
•   Lung cancer
  
•   Head and neck cancers
  
•   Melanoma
  
•   Leukemias
  
•   Lymphomas
  
•   Colorectal cancer
  
•   Multiple myeloma and myelodysplastic syndromes
  
•   Tumor lysis syndrome
  
•   Pain management
  
•   Chemotherapy-induced nausea and vomiting
  
•   Management of chemotherapy-adverse drug reactions

CASE QUESTION

What steps could J.B. have taken to improve his first day on an internal medicine rotation?

A TYPICAL DAY

The most common approach to internal medicine and specialty rotations is centered on rounding, or the meeting of a multidisciplinary team to review patients and make recommendations. In general, however, you typically will be required to arrive well before rounds are scheduled to begin. This early arrival allows you to review medical records and fill out monitoring sheets for all of the patients on a given service. Preceptors may also ask you to meet for prerounds, where you will informally present your patients to your preceptor. During this meeting, the preceptor evaluates your ability to interpret patient data and make therapeutic recommendations while giving you a chance to correct any mistakes before rounds truly begin.

At a predetermined time, the entire medical team will meet to begin rounding. The medical team may consist of a number of individuals, including (but not limited to) attending physicians, resident physicians, pharmacists, nurses, social workers, dieticians, and students. The team moves from patient room to patient room, discussing each case, reviewing patient information, and providing care. This is an ideal opportunity for you to be of service to the team. As medication questions arise, you can act as a resource for the team. If drug-related problems are discovered, you can make recommendations to improve patient care. You may also be called on to create presentations on relevant topics to help the team stay up to date on new research and guidelines. Depending on the individual rotation, rounds may take place a few times per week, once daily, or multiple times each day. When afternoons are free, time is spent working on assorted projects, patient counseling, continued monitoring, and attending grand rounds, or formal case presentations to large audiences of healthcare professionals. Typical projects encountered on clinical rotations may include formal case presentations, journal clubs, pharmacokinetic problems, research, manuscript write-ups, drug information assignments, or drug utilization reviews.

QUICK TIP

If there are other students participating in the rotation, use them to pregrade presentations and projects before turning them in to the preceptor. Getting the opinion of nursing or medical students may fill holes that are often missed when addressing only pharmacy issues.

For those rotations that are not located in teaching hospitals, additional techniques may be employed to get students involved in patient care. Instead of traditional rounding between patient rooms, a central location may be used to conduct rounds (also known as tabletop rounds). Other hospitals may utilize pharmacy rounds and written communication to convey pharmacy student recommendations.

PATIENT MONITORING AND THE MEDICAL RECORD

The medical record is the primary source of the important information used to evaluate a patient’s medication regimen. To make sense of the large amount of information present in this record, monitoring forms are used to place it in an organized, easy-to-follow framework.

The Monitoring Form

Although rotation preceptors may provide you with a monitoring form, students are usually encouraged to find or create a form that they are comfortable with. A high level of comfort with your monitoring form will allow for more efficient transfer of patient data and easier case presenting. If you attempt to use a new monitoring form for each rotation, any time spent with older versions is lost and the process of getting comfortable must begin anew. For a sample monitoring form, see Figure 8-1.

QUICK TIP

To shorten the time spent filling out a monitoring sheet, you can come up with your own abbreviation system, but make sure that you decipher your own code before presenting the case to the medical team!

History and Physical

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