An ER over capacity, but still usually bored?

After tonight, I will be half way done with my Emergency Department rotation.  So far it has been a lot less exciting than I thought it would be.  That's not to say they haven't been busy, it just hasn't been with people who have any pharmacy-related needs.  I'll explain more in a bit, but here's a little bit about what I have done so far.  The only thing the ED pharmacist really does every day is following up on lab results for people who came and left, but results took a day or two to complete.  We'll evaluate the appropriateness of what drugs they did receive and, if necessary, consult one of the doctors for a decision that either they are okay untreated or they need a prescription.  We then have to call the patient and discuss the results, and sometimes call prescriptions in to their pharmacy.  Other than that, the day is spent answering the many (usually simple) questions that come up from nurses or doctors and participating in some of the more complicated procedures.  So if it's a slow day, there's not much to do.  But if there are a lot of sick patients, it can be a lot more interesting and fast-paced (which has been 2 of the 9 days so far).  

New things I've seen or helped with on this rotation (and they're fewer and farther between than for most students, since I had such a fantastic rotation last month) are chest tube placement with conscious sedation, an ankle reduction (using multiple people's brute force to pull a broken ankle into a splint-able position), and a little more experience with sedation/paralysis for intubation and post-cardiac-arrest management.  Also, since it has been slow most of the time, I have gotten to sit in on a few basic things not directly related to pharmacy but good general knowledge items if I am to work in that environment someday.  I helped transport a couple patients to CT and watched the scan, watched a couple central line placements, watched a PA drain an abscess, and observed the triage process for a couple hours.  Overall, though, it has been a pretty slow 2 weeks in terms of the percentage of my total time spent being something interesting.  Besides all that, I have gotten pretty good at interpreting and treating urine cultures, STD results, and common women's health complaints because of the daily labs I review (sometimes up to 50 or so).  I've also gotten to dose a few things, mix some IV drips, administer some medications, and set up infusions with smart pumps.  Not too glamorous or complicated, but I'm glad I'm getting the repetition and experience so I can confidently do those things when I'm out on my own, wherever that ends up being.

The biggest reason that my opportunity for experience has been slow in light of a sometimes overcrowded ED is because most of the people that come in don’t have any sort of emergency at all.  I knew that this was the case, but I had no idea how huge the difference was between the number of people that belong there and the number of people who could be more appropriately served at another, less emergent facility.  I realize that my personal threshold for thinking about seeking emergency care is higher than the average American, since I was raised in a healthcare-heavy family and also know a fair bit about first aid and diagnosis of simple conditions from scouts and school. But I still can't see how some people view certain things as grounds for going to the ED. 

A lot of people come in for something that has been bothering them for a week, two weeks, sometimes even a few months.  If it's been an issue for so long, why is it all of a sudden an emergency that needs to be evaluated right away?  Another common issue is people coming in if they need a test or imaging but their doctor can't schedule them for a week or two.  Sure, you may not want to wait 2 weeks for an STD test or an ultrasound to confirm a viable pregnancy, but those things are not emergent.  If your doctor isn't helpful, there are a number of walk-in clinics that do those things regularly.  There are also a lot of people that come in who don't need anything that couldn't be picked up at their local pharmacy.  And there are also a lot of people who were advised to do something (medications, follow-up, etc.) and didn't, so they just come back to the ED.

"My knee has been hurting for 6 months and I just played basketball and it hurts more."  Hmm… I wonder if you should have seen a doctor 4-5 months ago?

"I 'went out' with a woman and later she called me and said I should 'get myself checked out.'"  Ok, so go to a clinic, STD center, or even urgent care.  It's not an emergency room issue.

"I've been constipated for 2 days." 

Go to the store and get some Miralax.  If it's been a week and you're in pain, sure, come in, but 2 days is not a big deal. 

"I was just moving a bunch of furniture and my side hurts now." 

Ya think you could have pulled a muscle?  Heard of ice or heat packs? Tylenol? Ibuprofen?   

"I was here yesterday and diagnosed with the flu and I'm not better."  You were told to rest, take Tylenol for your fever, and drink plenty of fluids.  Do you really expect that just because you were in the ED yesterday, your flu will just *poof* go away overnight?

"I came in last month for this condition and was told to follow up with my doctor but I didn't and now it's worse."  Why should we treat you again if you're just going to ignore us anyway? It's your own fault for not following up!

Those are all real patient complaints I've heard over the last couple weeks.  Of course, you can't say those things to people.  Doctors will, and sometimes do, explain to patients that they really don't need to come to the ED for these non-emergent concerns and social workers will follow up with the frequent repeat customers discussing the concept of "primary care physicians," partially because Medicare and Medicaid are not paying for ED visits in certain cases (such as a man who came in 12 times in 15 months for the same non-emergent complaint).  It's hard to say what the reason is for people not making better decisions about the acuity of care they require (I think I'll write more about that in a separate post), but the outcome is often that people who really do need emergency care are left in the waiting room or in ambulances diverted to other hospitals because all the beds and nursing assignments are occupied by people who really shouldn't be in that setting.  There are urgent care clinics they can go to, and primary care doctors associated with public health or Medicaid for those who may not be able to afford private insurance.  It may be an insurance coverage issue, but also may be a lack of health knowledge in the population that creates this issue.

It's easy to get sarcastic and complain about the scads of people who don't have any business coming to the Emergency Department, but I don't want to gloss over the people that really do need that level of care and I'm glad there are so many great health care systems in the area that can provide that care.  Though my days are boring a lot of the time, when they are busier it is because there are patients that do have conditions that are either life-threatening or need care more urgently than making a doctor's appointment could guarantee.  At those times, I learn a lot and it is rewarding to see the pharmacists' and my knowledge put to use.  So I'll keep trudging through the boring parts and hope that the next interesting things comes up again soon, not wishing for people to be really sick, of course, but so I can learn more and get more exposure and comfort with the things pharmacists are asked about and the things we have to do.

Don't you have a job to do?

When did people start losing their work ethic?  Being an extern at so many places this year has given me the opportunity to see a lot of different work environments and I have, at times, been appalled at the lack of motivation that people have.  I just can't understand how someone can be content sitting and doing absolutely nothing during their paid shift at work.  For one, it is pretty darn boring; doing almost anything, tedious or unexciting as it may be, passes the time better than doing nothing.  And secondly, most employers don't pay you just to do nothing; even if your specific tasks are done, doing something to help someone else or doing a task that's not "your job" would be a better use of your time (and by association, your employer's money).

Here's a scenario I'm finding repeats itself almost anywhere you go: someone has a set list of responsibilities, which they do very well for the first part of their shift.  But after they've done those things that are "their job," they just stop working.  Sure, they do things here and there, but the majority of the latter part of their shift is spent just sitting/standing there, chatting with coworkers (thereby distracting them from doing their own job), browsing their phone/email/the internet, or the thing that surprises me the most: absolutely nothing!  If I even try to do that, I go bored out of my mind!  When these chatty Cathy's pull me into a conversation, I try to be polite by chatting for a brief moment, but I always have this feeling of needing to get back to some task or another.  Working nights at Ostroms, even when it was dead slow and everything was caught up, I had to be doing something productive in some way, even if I was talking to coworkers at the same time (making copies, cleaning something, restocking, etc.)  There are times to relax when I'm happy doing absolutely nothing but socializing, but when I'm doing a job, especially if it's paid, that isn't an option to me. 

The worst for me is when I am reporting to someone who just sits there for half of their shift because in some situations, if they don't give me a task, I can't really do anything either.  I try to find things to do (usually reading about topics I don't know) but there comes a point when I can't do anything more and it is excruciatingly boring to just sit in a chair, mindlessly clicking around at a computer for 6 hours of an 8 hour shift.  Maybe preceptors that don't really do much themselves shouldn't take students; their doing nothing means the student doesn't have much to do or learn, plus it just shows the student how lazy and unmotivated they are.  (I try not to think about the fact that people like this get hired over people with good work ethics just because they've been there longer or they know someone, or they have a better resume…)

What makes it worse is when "your" job is done but other people are running around like headless chickens.  This happens in the ER a lot.  It can be really busy in terms of patient numbers but not in terms of difficult or critical patients.  There will inevitably be one or two people doing nothing because their patients are taken care of.  It would be a better use of their time and a really helpful thing for their coworkers if they did something, anything at all, that was productive whether it be cleaning up a blood spill, running to get supplies, getting vitals, or answering call lights for someone else's patients.

Scenarios like that also make me wonder if costs of services would go down if people worked harder.  If there's someone who doesn't really do anything for the last 2 hours of their shift, do they really need to be scheduled that long?  If a nurse delegates her tasks to a technician and then sits and gossips for half an hour, do they really need to pay that many nurses at a time?  As an employer, I wouldn't expect people to work themselves ragged non-stop for their whole shift (because there are busier times and times that are more relaxed – that balance is necessary for sanity during the crazy times), but I would expect that if they have some down time they do something, insignificant or simple as it may be, as long as it is in some way productive.

I guess I'll never understand why people that don't have a work ethic are that way.  Though they might not have the technical skills, I can name a ton of 14-18 year olds (camp staff) that could do a much better job than people I see in the workforce.  At camp, it's just expected that you keep yourself busy from 7:30 am to 10 pm.  If your job is done, you find somewhere else to help out or something else productive to do.  It's really too bad that that attitude isn't common in the general work force.  Wasting their employers' money aside, I still just can't figure out how people can feel content (or not guilty in some way) doing absolutely nothing for periods of time at work.  It's frustrating for those that work hard (or want to but can't, because of the lazy-bums), but hopefully it is something that puts those hard workers ahead when it comes to hiring and consideration for leadership positions.  I guess that work ethic is one of the reasons that adults coming to Camp Parsons say they’ll hire any staff member in a heartbeat; it's not the norm and it's a desirable and valuable quality to have.

An Unwelcome Change of Pace

As I have mentioned, I LOVED my January rotation. I could go on and on about why I liked my preceptors, the facility, and the other staff I got to work with. But I'll refrain for now. There is something I noticed though. What didn't strike me as obvious at the time, but I'm quickly realizing, is that a big difference in these rotations is in the perspective from which you are taught/treated. I now realize that the difference between finding annoyance or reward in an experience has more to do with that perspective/attitude than the tasks you actually do (though that can have a big effect, too, if its a major deficit).

Two of my inpatient rotations were at places that don't do any formal teaching. There's no residents (for the most part) and there are traditionally fewer students, also in part due to their locations. I took it for granted at the time, but I was treated more as a colleague than a student. I had plenty of oversight and opportunity to get help when I needed it, but I got an attitude of more "we don't have as many students, I don't exactly know what to do with you, so you can do the things we do." That was, for me, much more enjoyable and educational. Of course, at first I got a lot more guidance and direct supervision but I was left more to do my assigned tasks and to check in with questions or approval before taking action.

The alternative is what I have experienced at a facility that DOES do formal teaching. There is a lot more hand-holding and I don't feel like I am viewed as someone who is at the level in education that I am. I don't like being asked if I have questions every ten minutes. I am an adult, almost a doctor (which I say with the highest level of humility...just making a point) it should be assumed that if I have questions, I'll ask them, which I frequently do.

Here's another difference: it is very common for preceptors to ask students questions ("grill" them). But there comes a point when that is overkill. Sure, for most things it is worthwhile to discuss the underlying basics as part of the topic, but I don't think it's necessary to explain EVERYthing. A specific example is asking me: are you familiar with dosing of alteplase for ischemic stroke? If I say yes, that I did a presentation on stroke protocols and dosing, I would expect that the pharmacist trust my response and confidence, and not make me regurgitate "0.9 mg/kg total up to 90 mg with 10% as an IV bolus followed by the rest as an infusion over an hour." I'm not saying it's not reasonable or useful to "grill" the student, but the manner in which you do it makes a huge difference. It probably sounds like I'm just whining about minor things, and its difficult to articulate what I mean, especially when non-verbal cues play a role, but the issue I have is when I feel like I'm answering things for the sole reason of proving I know them instead of as a piece in basing or facilitating a discussion on the topic.

While appropriate for a first experience too much of these things in a more advanced rotation make for a little bit of "arrested development" and feels like a huge slow-down in my development of the clinical skill-set I've been so excited about lately.

I can think of a couple possible reasons for these differences. One was immediately apparent when I compare these more formal-teaching rotations to school (you know, that three-year period I just hated for these exact reasons...?) and all those "educational methodologies" they beat to death. You can tell pretty quickly if someone is a newer graduate that bought into that stuff. The other reason I see is that the majority of students aren't like I am when it comes to interpersonal skills and confidence. I am a pretty independent and non-soft-spoken person, especially compared to some of my classmates. If you give me a task, I can do it on my own and wouldn't hesitate to ask for help if I need it, or speak up if I don't know something. I'm not afraid of talking to people (calling patients, discussing issues with physicians, etc). The fact that many students need this excessive hand-holding is probably why it happens. I guess teaching hospital preceptors are so used to doing it that it's become the standard.

(So am I implying that the school accepts a whole bunch of people who don't possess the confidence, independence, and communication skills that are necessary for a pharmacist to have? Hmm... )

Now I'm making this conclusion pretty early, so nothing says it won't change over time. My point, though, is that students at this level should be held to a high standard. If they are new to something, guide them through it and build trust in their skills and judgment as you get to know them and as they become more comfortable - that's part of teaching. But also realize when you can skip the hand-holding and treat the student as less of a child (a little harsh, but that's how it feels sometimes) when they prove their competency right away. Someone that asks questions a lot doesn't need to be asked if they have more. And someone quick to admit they don't know or remember something shouldn't be questioned every time they say they do (vs. if they dodge questions or try to pull answers from their backside). If you can bypass the more elementary concepts, there's way more time to go into things you wouldn't otherwise get to. It can be more educational for the student as well as less monotonous for the preceptor.

This realization in the difference in teaching styles of smaller vs. large/teaching hospitals is very valuable for my job searching as well as (and more importantly) my possible residency prospects. It's something I'll have to look at closely to determine if a particular residency would be a year of being like a CIT of pharmacy or, the way it should be, as a graduate who is almost a colleague and just gaining experience in a more structured setting than OTJ training. In situations like this, I just have to plug away, go along with their methods, and hope that enough of proving I can be treated like an adult will result in exactly that. If not, I'll still have learned something at the end, even if it was not as much as I could have and was through a process of baby steps and extra hoops to jump through.

When it comes down to it, I am still just a student. All responsibility lies on the preceptor when the student is gone or if/when something goes wrong, but tailoring the experience to each student's personal and clinical abilities and knowledge in order to find a point between holding their hand and totally throwing them off the deep end is important at this point in professional education. It can still be done with sufficient oversight, effective teaching, and appropriate guidance and, while it may be impossible for those students whose skills are lacking, will make a very meaningful difference for those who can handle it.

(If only everyone was as confident, responsible, and able to communicate as the Camp Parsons Staff...)

A Month Well-Spent

This past Thursday was the last day of my ICU clinical pharmacy rotation.  That means I am more than halfway through my academic year: five done and four to go.  Out of the five rotations I have done, though, this was by far the most educational, interesting, and potentially life-altering.  My previous rotations, even the best of them, played themselves out to the end which usually came at a point where I was ready to move on to the next one, even if the experience was very positive.  However, this rotation left me wanting more.  Other pharmacy schools use six-week rotations (instead of the four weeks at UW) and this is one month where I wish I had those two extra weeks.  The things I did, and the things my preceptors did as part of their regular day, were the things I can see myself doing, and enjoying doing, for years to come.  As an example, in school I would read things because they would be on the test and because they were a little interesting sometimes.  But in this last month (and the one previous, to some extent) I read those same types of things because I felt a drive to learn more.  When I came across something I didn't know or remember from school, I was actually excited to figure it out; find research papers, look up fundamental concepts (microbiology, biochemistry, etc.) to cement what I found, learn about any related issues, and (when the prompt came in the form of a "drug information" question from a pharmacist or doctor) tell other providers a little about something new or interesting I learned.  Clinical Pharmacy keeps me constantly thinking, by expanding and finding the newest changes regarding my knowledge, and ultimately using that knowledge to either support the medical team or directly improve a patient's stay in the hospital.

My recent post about clinical pharmacy ("My Career Revelation") was sort of left hanging.  As I eluded to, not having this revelation until January means that I have missed the cutoff for residencies.  A Pharmacy Practice Residency is a one-year program for pharmacists (almost exclusively new graduates) to gain experience in clinical pharmacy.  As with most professions, those doing the hiring are looking for candidates with experience.  This is especially important in pharmacy where, as a new graduate, you are often put in positions where you have little immediate support in making decisions quickly (e.g. working the night shift as the only pharmacist in the hospital when a decision must be made or a question answered that couldn't wait until morning).  Because of that (and probably some other factors), a pharmacy manager would find more difficulty in someone fresh out of school over someone with experience.  So by doing a residency, you have an intensive year as a paid (though at a lower rate), licensed pharmacist, but who has extra guidance and support during the time you further develop and become more comfortable with clinical skills.  A year of residency training is supposedly viewed as approximately equivalent to three years of regular work experience when it comes to hiring.  Beyond that first year, you can also do a second-year residency in a specific discipline (e.g. critical care) to even further hone and become more comfortable with your skills and knowledge.  Thus, residencies are beneficial to a new pharmacist by giving them more knowledge and confidence before being thrown into the deep end, as well as by providing them with a way to get the experience that is almost always needed to be considered for a job.

Applying for residencies is even more complicated than applying to college.  There are applications for each individual site but they all go through a central agency.  Once a site decides they are interested in you as a candidate, you are brought in for an interview.  You may interview at a few to a dozen different sites, and at the end of that process, you rank your preferences.  Each residency director does the same: ranks their preferences of which candidates they would most like to extend an offer to.  Once all those rankings and choices are submitted, a computer does some sort of algorithm that "matches" sites to candidates.  As you would expect, that process is pretty long which is why thinking about applying in January is far too late when the process started in September. 

So what do I do?  The first things I heard were that candidates are not considered for a clinical position without a residency under their belt.  I heard this from the school as well as managers at hospitals I've rotated at.  That being said, more of the young (more recently graduated and hired) pharmacists I've met hadn't done a residency than had.  I thought that a residency was a make-or-break part of your job application, when in fact, someone who hasn't done a residency but is a fast learner and relates well to other people could have a leg up on someone with a residency but who lacks interpersonal skills or a drive to succeed.  My plan, as of now, is to look for a job in a hospital that will hire me without a residency.  That may not, and likely won't be the clinical job I'm looking for.  As an entry-level pharmacist, it will likely be a weekend or evening job working hours that people with more tenure don't want to work.  But if I can find a door to get a foot into, it would be an opportunity to get on-the-job experience that may lead into that clinical position I want in the end.  And if it doesn't, it would be a way of making an income as well as keeping myself current on clinical topics (vs. spending nine months in a QFC counting pills and losing knowledge to a lack of its use) until next year's residency cycle begins and I can apply at that time.  That sounds like I have it pretty well figured out, right?  Fundamentally, I think I do, but what I need to figure out now it is who to talk to, where and how to apply, and where to put my name out so I will have somewhere to work come summer.  Graduation seemed so far away even a month ago, but now that I'm figuring out where I'd like to end up and how close June 14^th actually is, I'm realizing I have a lot to do in the upcoming months.