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AMBULATORY CARE ROTATION TIPS:

Setting the Scene:

When a student moves from a didactic to a clinical setting, the stakes change. Information that once needed to simply be memorized now needs to be conjured on demand for real-life, patient-centered applications. Suddenly, there is a need for a different mindset. There are no more FYIs, and the expectation is to demonstrate a more holistic understanding of the disease states we spent a good 2-3 years learning. Questions that were once ignored or never asked become a daily occurence, and the new normal is to think outside the box. What are your resources? How will you find your information?

Sound scary? Wouldn't blame you. This transition, at least in the beginning, may be overwhelming and even perplexing. It is my good hope, then, that this guide will help orient the mind towards what may be expected (both professionally and clinically), and ease any clumsy nerves that stop you from being the rockstar that you are, and can also be, at your rotations. I'll start off with ambulatory care and update and add more as the year progresses.

A quick disclaimer: this is not a definitive guide on how to approach and successfully complete/pass rotations. These are simply lessons I learned along the way and what I feel will be beneficial if shared. You must abide by the expectations and requirements set by your school, preceptors and any other parties involved in the successful completion of your rotations. Their requirements override anything I say, so please bear that in mind as you go through the following. Finally, I do hope that this little write-up serves as your springboard to the clinical/administrative world. :) I sincerely wish you the best and want you to enjoy your journey in this final leg. You've worked hard to get here, and here's to you doing great things for the rest of the year!

- Ravi Soni

The Details:
1. What is ambulatory care?

Generally speaking, this is medical service provided in a setting where patients do not get admitted. In other words, it is treating patients on an outpatient basis as opposed to admitting them for inpatient services (such as in a hospital or a rehab facility). For pharmacists, this often means interviewing, counseling and creating care plans for patients who are or will be taking chronic medications for diabetes, hypertension, dyslipidemia, etc. You will likely encounter both new and follow-up patients.

2. What are some skills (pre-existing or those that you will pick up during the rotation) which will help you succeed in an ambulatory care setting? These are also some of what you preceptors will expect you to get better at as the rotation progresses – preceptors are usually fair and understand that a student is unable to do all this on day one.

a. Patient Work-up
Understanding SOAP notes (specifically the template used at your clinic) and what goes into each of the four sections is something you should brush up on. While you will be making notes for new patients, do realize you may see many follow-up patients, and for them, more investigative work will be needed.
To that end, be prepared to understand the electronic health record (EHR) system at your site. Get to know how to access labs, imaging, demographics, prior notes from previous visits, and other pertinent data. The sooner you get acquainted, the easier the patient work-ups will be.

b. Clinical Knowledge
Thoroughly understand the drugs, their side effects, counseling points and brand and generic names. Also understand treatment algorithms in diabetes, hypertension, dyslipidemia, hypo/hyperthyroidism, and other disease states in which patients take chronic medications (more information on the big three below). Also be well-versed with over-the-counter options for the same.

c. Communication Skills
More likely than not, you will eventually interview patients. It is essential to develop a flow for your interview sessions, and it will only come with time and practice. Observe and take notes of your preceptor’s sessions, if allowed, and practice ‘til you perfect it.
Presentations are going to be a part of any clinical rotation you have. Working on assignments (individual or group) before the deadline is imperative. Practice timing your presentations, polishing your transitions, and readying yourself with answers for the same. Due diligence will help you create great and accurate presentations. Do not forget to reference your sources, and brush up on AMA if needed.
Written work is an equally important (and required) component of most ambulatory care rotations. You will be summarizing guidelines, treatment algorithms or other literature as well as creating drug charts for your usage throughout your rotations. These activities are rather educational, and it will help you to make most of the opportunity. You can use your charts and summaries not only during rotations but also during your NAPLEX prep.

d. Interpersonal Skills
Outside of presentations, you will still have other instances where either your or your peers’ mannerisms and work could be the rate limiting step to a better rotation experience. Be tactful in such situations and ensure that rotation is a great experience for both you and your teammates. Be firm but also understanding. Hold up your end of the deal in any collaboration, and always keep contact information of all your teammates handy.
For patients, one of the biggest lessons I learned was not to be overly expressive in either good or bad news for the patient. Also, be careful with statements that may give patients false hope, especially if future outcomes from their treatment are unknown. Be professional, courteous and empathetic.

e. Journaling and Staying Organized
This is as old as humankind. Tried and tested, and true to form. At all times, a notepad and a pen will be your best friends on your rotations. Take notes of everything new you come across. How did my preceptor handle this situation? How did they talk with the agitated patient? What did they do to de-escalate the situation? How did they know that this was the next appropriate clinical step to take if treatment failed twice? What are their resources? How do they look up information? How do they get continuous updates in their field? In terms of patients, what kind of questions do they usually ask? What are some common concerns that patients usually bring up with this disease state? You will come across many such situations. Note them all. Jot them down. Keep them safe. This is one surefire way of becoming a great learner and an outstanding student. If you make it a habit to review your notes (repetition is key), your preceptor will love you for it, because you likely won’t ask the same question twice.
Another reason to keep good notes is so that you have logs of difficult or behavioral situations that you can review and talk about during your interviews later in the year. It is almost certain that you will forget them unless you write them down.
For organization, understand the scope of the rotation. You may have various topic discussions, guidelines, individual presentations, group presentations, journal clubs and more. For each of them, you will have multiple resources. It is best to set up a folder and divide it categorically for easy access to materials when you need them.

f. Outcomes and Feedback
If personal and professional growth is your motivation, engage in a conversation with your preceptor to see whether they can give you more feedback than just during midpoint and finals. Oftentimes, it helps to receive weekly (and sometimes even daily) feedback on your performance. Getting that objective feedback only helps you fine tune your clinical and professional quirks (which, for better or worse is understandably subjective). Receiving and acting on feedback is a skill, and if you make it a habit, you will grow faster than most other students.

g. Any NAPLEX Preparatory Course
Read your favorite NAPLEX prep course on the big three disease states mentioned above. Your preceptors will often ask you questions that are easily accessed through such sources. Do make sure the information is accurate.

h. Documentation, Documentation, Documentation
Is there a way to log your hours? Did you save all your assignments you turned in? Did you send emails/assignments to your preceptor as well as all other professors if requested? Did you turn in your assignments on time, and via email, and you made sure not to delete any such emails until you graduate? Do not ever go lax on preserving paperwork and documentation for all the work that you do. It’s just something that is non-negotiable, regardless of what rotation you’re doing. Once again, do not go easy. Preserve, keep, maintain, document everything that you do, and do not violate any school, site, preceptor, state or federal policy.

3. What will make you stand out?

a. Professionalism (general, applies to any rotation):
Punctuality – Take traffic delay times into account, and assume that there will be a 15 minute delay. If rotation begins at 8 am, be ready to go at 8 am, and not just be arriving at 8 am.
Integrity of work and character – Work that is assigned to you is best done only by you. Every individual brings something unique in how they format their notes/charts/summaries, and even interpretations of the same. The work that you do will not only help you avoid shortcuts (which is desirable here), but also help with comprehension and retention of information, and gives your peers a chance to look at the same information in a different way. Give your best effort regardless of what you think is going to happen to the assignment. Even if your effort does not get recognition, you will have prepared a great resource for yourself, and that is less work to do in the future (especially during NAPLEX prep).
Expectations and communication – Know what you can and cannot do. Know what are and aren’t expected to do. If ever in doubt, ask whether you have the authority to perform the said task. Assumptions often end up with bad and unnecessary consequences.
Read the student manual - once before and once during the rotation. Sometimes we get comfortable with preceptors and act in ways not allowed by policy. Be always cognizant of the lines and the limits.
Be fluent with the rotation outcomes and ensure you are making progress over the 6 weeks.

b. Showing positive intent and a humble and learning attitude
Do you perform well even when you are not being supervised? Are you the first one out as soon as the clock hits go-home time, or do you stay back to ensure your work is complete, your desk is clean and is ready to be used by the next person? Do you spend extra time at home to know more about some fascinating discussion that happened at the rotation? Do you know your disease states in a bit more depth than taught during your didactic years? These never go unnoticed.

4. Clinical food-for-thought for DM, HTN and DLD

a. Work in progress

5. What are some resources where you can find information?

a. Lexicomp, Micromedex, UpToDate/DynaMed
b. Manufacturer websites and/or package inserts
c. Your site’s policies, protocols and procedures
d. Access Pharmacy (may be available through your school’s website)
e. Practice guidelines
DM   - ADA SOC 2018, AACE/ACE 2015
HTN - ACC/AHA 2017, ASH/ISH 2014, JNC-8 2014
DLD - ADA SOC 2018, NLA (parts 1 and 2) 2015, ACC/AHA (updated 2014)
f. Lecture presentations, your school notes/charts/summaries
g. Pubmed (do you have your library access to NCBI to avail of articles not in the public domain?)
h. Nevada Statutes (for legal references)

6. Further Reading

a. Pharmacy Student Survival Guide, 3rd edition.