Pharmacy Services

Inpatient Oncology Rotation

 
Preceptors:

Michael R. Filtz, PharmD, BCOP
Courtney Cavalieri, PharmD
Thu Tran, PharmD, BCOP
Sara Hiller, PharmD

Office: 7-4404
Hours: 7:00-5:30
Pager: 339-9229

 
Site Description:

The Huntsman Cancer Hospital has 100 inpatient beds, 25 of which are covered by the Oncology service. Pharmacists on this service:

  • Participate on Oncology interdisciplinary medical teams
  • Ensure safety & appropriateness of chemotherapy regimens
  • Educate residents & students

The clinical pharmacists work with the oncology team to optimize pharmaceutical care of inpatients on this service.  Each team may consist of oncology nurse practitioners, physician assistants, medicine residents, medicine interns, oncology fellows and attending physicians.  Responsibilities include rounding with the team, medication management, admission and discharge medication reconciliation, and patient counseling.  In addition, pharmacists perform chemotherapy order entry and participate in a double check system for every chemotherapeutic agent ordered.  A significant part of the pharmacist’s time is dedicated to teaching pharmacy/medical students and pharmacy residents.

 
Rotation Description

Typical expectations of residents include the following: working up approximately 4-16 oncology patients each day, interacting with the nurse practitioners, physician assistants, nurses, physicians, and oncologists to identify and resolve medication-related problems for these patients, attending rounds every morning, discussions with the preceptors on a variety of oncology topics, formal patient presentations to the preceptor, attending weekly oncology pharmacy resident “killer sessions”, attending pharmacy grand rounds when schedule permits, responding to drug information requests from the providers, and possibly precepting pharmacy students.  The resident will provide and document therapeutic drug monitoring services for patients on their team receiving drugs requiring monitoring.  The resident is responsible for providing and documenting education to patients on their team who will be discharged.

Good communication and interpersonal skills are vital to success in this experience.  The resident must devise efficient strategies for accomplishing the required activities in a limited time frame. 

 
Disease States:

Common disease states in which the resident will be expected to gain exposure through literature review, topic discussion, and/or direct patient care experience including, but not limited to:

  • Lung cancers
    • Non-small cell adenoma, squamous cell, small cell
  • Male predominate cancers
    • Prostate, Testicular, etc.
  • Female predominate cancers
    • Breast, Ovarian, Cervical, etc.
  • Abdominal cancers
    • Colorectal, Pancreatic, Hepatocellular, Renal Cell, etc.
  • Coagulopathies
    • DVT, PE, etc.
  • Infectious Diseases
    • Neutropenic fever, skin and soft tissue infections, pneumonia, etc.
  • Sarcomas
    • Myosarcomas, rhabdosarcomas, Ewings sarcoma, etc.
  • Oncologic Emergencies
    • Hypercalcemia, Cord Compression, etc.
  • Palliative Care
    • Pain control, constipation, nausea control, etc.

3) Goals and Objectives

The goals selected to be taught and evaluated during this learning experience include:

Objective Number  (Level of Learning Required) & Description

Teaching Method(s)

Related Rotation Activities &
Minimum Number of Times the Activity is Repeated to Ensure Completion of the Objective.

Goal R1.1 Identify opportunities for improvement of the organization’s medication-use system.

R1.1.1    Explain the organization’s medication-use system and its vulnerabilities to adverse drug events (ADEs).

Direct Instruction
Modeling

  • The resident will review Medication Management Policies related to our formulary system.
  • The resident will be instructed on how to submit ADE reports and will submit reports when appropriate.

R1.1.2    Analyze the structure and process and measure outcomes of the medication-use system.

Coaching
Facilitating

  • The resident will work with inpatient, outpatient, retail, and clinic pharmacists and technicians to understand the medication system..

R1.1.3    Identify opportunities for improvement in the organization’s medication-use system by comparing the medication-use system to relevant best practices.

Direct Instruction
Modeling
Coaching
Facilitating

  • The preceptor will review the Medication Management Policies with the resident.
  • The resident will identify areas where our practices diverge from best practice and propose improvements..

Goal R2.1 Establish collaborative professional relationships with members of the oncology health care team.   

R2.1.1   Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of the interdisciplinary team.

Direct Instruction
Facilitating

  • The resident will attend rounds every morning to provide recommendations on medication therapy as well as be available in the team room before and after rounds to answer the team’s medication related questions.
  • One formal presentation on a oncology topic of choice will be formally presented to either the oncology team during the rotation. The presentation should be between 20 – 30 minutes in duration.

Goal R2.2 Place practice priority on the delivery of patient-centered care to patients.

R2.2.1    Choose and manage daily activities so that they reflect a priority on the delivery of appropriate patient-centered care to each patient.

Modeling
Coaching

  • Preceptors will model the prioritization of various critical conditions.
  • Residents will devise an approach to investigating which patient(s) requires the most attention at the beginning of their day.

Goal R2.4 Collect and analyze patient information.

R2.4.1    Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team.


Direct Instruction
Modeling
Coaching
Facilitating

  • The preceptor will review with the resident the institution’s medication related policies and procedures related to writing chemotherapy and proper abbreviations.
  • The resident and preceptor will discuss acronyms for chemotherapy regimens as patients are treated with them and during weekly topic discussions.
  • The resident will evaluate patient’s alternative and complementary treatments for ADRs and drug interactions with chemotherapy as the need arises on rotation.
  • The resident will lead weekly topic discussions (signs/symptoms, epidemiology, risk factors, prevention, treatment, outcomes, and medications (PK, MOA, dose, etc) used in that disease state) on preset oncology topics as well as daily mini topic discussions based on current patients.
  • The resident and preceptor will discuss quality of life of specific disease states and regimens during weekly topic discussions and for specific patients based on the therapy being given.

 

R2.4.2    Determine the presence of any of the following medication therapy problems in the current medication therapy of an individual with cancer:
1.             Medication used with no medical indication
2.             Patient has medical conditions for which there is no medication prescribed
3.             Medication prescribed inappropriately for a particular medical condition
4.             Immunization regimen is incomplete
5.             Current medication therapy regimen contains something inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration)
6.             There is therapeutic duplication
7.             Medication to which the patient is allergic has been prescribed
8.             There are adverse drug or device-related events or potential for such events
9.             There are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions
10.          Medical therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others
11.          Patient not receiving full benefit of prescribed medication therapy
12.          There are problems arising from the financial impact of medication therapy on the patient
13.          Patient lacks understanding of medication therapy
14.          Patient not adhering to medication regimen

 

Direct Instruction

  • The preceptor and resident will discuss chemotherapy regimens (efficacy, toxicity, dose and duration, etc) used in the outpatient vs. inpatient setting.
  • The preceptor and resident will discuss benefits and risks of chemotherapy regimens during weekly topic discussions and for specific patients as they begin new treatment.
  • The preceptor and resident will review admission and discharge medications for these problems.
  • The preceptor and resident will review all new therapies and therapy modifications for these problems.

R2.4.3    Using an organized collection of patient-specific information, summarize patients’ health care needs.

Direct Instruction
Modeling
Coaching
Facilitating

  • The resident will discuss with the preceptor (and update the daily sign out with) the prioritized problem lists and current treatment and recommendations for each patient.

 

Goal R2.6:            Design evidence-based therapeutic regimens.

R2.6.1   Specify therapeutic goals for a patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and quality-of-life considerations.

Coaching
Facilitating

  • The resident will choose a topic to provide a formal presentation on to the team.
  • The resident will have the opportunity to develop the presentation to an interdisciplinary team that could include MDs, PAs, NPs, pharmacy and medical students, and RNs.
  • The resident will have objective for his or her presentation which will be evaluated by a case question or open ended questions.

R2.6.2   Design a patient-centered regimen that meets the evidence-based therapeutic goals established for a patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles.

Coaching
Facilitating

  • For the one formal presentation the resident can use a case or ask open ended questions to assess the audience’s understanding.

Goal R2.7 Design evidence-based monitoring plans.

R2.7.1    Design a patient-centered, evidenced-based monitoring plan for a therapeutic regimen that effectively evaluates achievement of the patient-specific goals.

Coaching

  • Based on patient-specific information gathered (as above), residents will be able to discuss expected outcomes based on disease state, co-morbid conditions, and individual patient goals. Residents will outline plans for monitoring these outcomes, including timeframes of when different sequelae or effects might be expected.
  • Residents are expected to investigate primary and tertiary literature related to each medication-related problem to determine (a) reasonable course(s) of action for each patient. Based on pharmacokinetic parameters of each medication involved and reported timelines of possible side effects.
  • Residents will present assigned patients to preceptors on a daily basis, incorporating their ideas on evidence-based plans for medication therapy monitoring.

Goal R2.8 Recommend or communicate regimens and monitoring plans.

R2.8.1    Recommend or communicate a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team and patients in a way that is systematic, logical, accurate, timely, and secures consensus from the team and patient.

Modeling
Coaching

  • Residents will present their ideas for initiation or alteration of medication therapy plans to the team in an assertive, yet polite, manner and be prepared to reference pertinent primary and/or tertiary literature supporting their recommendation(s).
  • Residents will be respectful of other team members if they choose to only partially accept the resident’s plan or do not accept it at all. Subsequent discussions with the preceptor should occur to discuss follow-up plans if the team does not implement the resident’s ideas or if the patient chooses to decline such intervention(s).
  • Residents will be provided appropriate feedback if their recommendations are not succinct and/or provided at the appropriate “teachable moment” in a timely manner during rounds.
  • Residents will follow-up to ensure their recommendations were followed through on as indicated during or after rounds.

Goal R2.12 Document direct patient care activities appropriately.

R2.12.1  Appropriately select direct patient-care activities for documentation.

Direct Instruction
Modeling
Coaching
Facilitating

  • Write daily progress notes on all or some of the patients, depending on patient load and the resident’s comfort level with oncology practice.
  • Understand what interventions or issues are typically documented by oncology pharmacists based on the various audiences that read these notes, and at what point in the patient’s care (i.e. transfer, discharge).

R2.12.2  Use effective communication practices when documenting a direct patient-care activity.

Direct Instruction
Modeling
Coaching
Facilitating

  • Residents will be provided ample feedback on how to better communicate various medication-related issues so that their recommendations are well received by other health professionals and well understood by other pharmacists.

R2.12.3  Explain the characteristics of exemplary documentation systems that may be used in the organization’s environment.

Direct Instruction
Modeling
Coaching
Facilitating

  • Residents will communicate what parts of the documentation system are valuable and which are too much or too little information.

Goal R5.1 Provide effective medication and practice-related education, training or counseling.

R5.1.1    Use effective educational techniques in the design of all educational activities.

Coaching

  • Lead presentation(s) on medication-related topics of the team’s choosing, possibly including a journal club or at least one oncology topic

R5.1.2    Design an assessment strategy that appropriately measures the specified objectives for education or training and fits the learning situation.

Coaching

  • Include planned questions following or during journal club discussion to verify audience understanding of material.

R5.1.3    Use skill in the four preceptor roles employed in practice-based teaching (direct instruction, modeling, coaching, and facilitation).

Modeling
Coaching

  • Residents will be encouraged to precept other learners (IPPE/APPE/medical students) when schedules allow.
  • Discussions on how to approach precepting will occur if schedules allow the resident to precept a learner.

R5.1.4    Use skill in case-based teaching.

Coaching

  • Any patient cases involved in topic or journal club discussions should highlight teachable moments.

R5.1.5    Use public speaking skills to speak effectively in large and small group situations.

Modeling
Coaching

  • Residents are expected to effectively present in a small-group setting as well as on daily rounds and for any topic discussions they lead. Aspects to be evaluated include tone, pace, inflection, and appropriate level of language based on the audience’s expected background understanding.

R5.1.6    Use knowledge of audio-visual aids and handouts to enhance the effectiveness of communications.

 

  • Residents will have a choice to present handouts and/or visual aids for their chosen topics.

Goal R6.1 Use information technology to make decisions and reduce error.

R6.1.1    Explain security and patient protections such as access control, data security, data encryption, HIPAA privacy regulations, as well as ethical and legal issues related to the use of information technology in pharmacy practice.

Coaching

  • Residents will discuss relevant regulations during rotation orientation and practice according to those laws.

R6.1.2    Exercise skill in basic use of databases and data analysis software.

Coaching

  • Residents will use various resources such as DOPL, cerner, Micromedex, and pub med.

R6.1.3    Successfully make decisions using electronic data and information from internal information databases, external online databases, and the Internet.

Coaching

  • Residents will incorporate electronic guidelines such as NCCN into decision making.

Goal E6.1 Identify a core library, including electronic media, appropriate for a specific practice setting.

E6.1.1    Use knowledge of standard resources to select a core library of primary, secondary, and tertiary references appropriate for a specific practice setting.

Modeling
Coaching

  • Residents will be exposed to preceptors core literature library and will be taught how to develop, organize, and maintain a core library for current and future reference.

 
Reading and Preparatory Work:

  1. IDSA Febrile neutropenia guidelines 2010
  2. Oncologic emergencies: Diagnosis and Treatment  Mayo Clin Proc. 2006;81(6):835-848
  3. Adult Acute Myeloid leukemia. Mayo Clin Proc. 2006;81(2):247-260
  4. Medical Progress: Acute Myeloid Leukemia NEJM 1999; 341(14):1051-1062
  5. Walczak JR, Carducci MA. A Practical Approach to Management of Recurrent Disease. Mayo Clin Proc. 2007;82:243-249.
  6. Jabbour EJ, Faderl S, Kantarjian HM. Adult acute lymphoblastic leukemia. Mayo Clin Proc. 2005;80:1517-1527.
  7. Jabbour EJ, Estey E, Kantarjian HM. Adult Acute Myeloid Leukemia. Mayo Clin Proc. 2006;81:247-260.
  8. ASHP Guidelines on Preventing Medication Errors with Antineoplastic Agents. Am J Health-Syst Pharm. 2002;59:1648-1668.

Topics to be reviewed:

  1. Oncologic emergencies
  2. Neutropenic fever
  3. Palliative Care
  4. Anti-emetic Agents

Typical Schedule

Typical hours are 7AM until 5:30 PM
Monday: Overview of patients, Patient care rounds
Tuesday: Overview of patients, Patient care rounds
Wednesday: Overview of patients, Patient care rounds, Oncology Pharmacy conference  
Thursday: Overview of patients, Patient care rounds, discussion topic
Friday: Overview of patients, Patient care rounds, topic discussion, patient presentations

 
Preceptor Interaction:

Daily:
8:30 Pre-rounds with resident
9:00 Team rounds with resident and team
1:00 – 2:00 Preceptor patient discussion.

 
Communication:

  1. Daily scheduled meeting times:  Residents to prioritize questions and problems to discuss during scheduled meeting times as listed above.
  2. E-mail:  Residents are expected to read e-mails at the beginning, middle and end of each day at a minimum for ongoing communication.   This is appropriate for routine, non-urgent questions and problems. 
  3. Office extension:  Appropriate for urgent questions pertaining to patient care.
  4. Pager:  Residents to page preceptor for urgent/emergency situations pertaining to patient care
  5. Personal phone number: Provided to resident at time of learning experience for emergency issues.

 
Expected progression of resident responsibility on this learning experience:

(Length of time preceptor spends in each of the phases will be customized based upon resident’s abilities and timing of the learning experience during the residency training year)

Day 1:  Preceptor will review learning activities and expectations with resident.

Week 1: Resident to work up approximately 4-8 of the team’s patients and present to preceptor daily.  Preceptor to attend and participate in team rounds with resident, modeling pharmacist’s role on the health care team. 

Week 2:  Resident to work up approximately 8-12 of the team’s patients and discuss problems with preceptor daily.  Preceptor to attend team rounds with resident, coaching the resident to take on more responsibilities as the pharmacist on the team. 

Weeks 3-4:  Each week the resident is expected to take over the responsibility of working up more of the team’s patients, continuing to discuss identified problems with preceptor daily.  Once the resident is able to take responsibility for all patients assigned to the team, the preceptor will no longer attend team rounds, but will continue to facilitate the resident as the pharmacist on the team. 

 
Evaluation:

Residents will be provided with verbal feedback on a frequent (at least every other day, possibly several times daily) basis. ResiTrak will be used for documentation of scheduled evaluations. For all evaluations completed in ResiTrak, the resident and the preceptor will independently complete the assigned evaluation and save as draft.  The resident and the preceptor will then compare and discuss the evaluations.  This discussion will provide feedback both on performance of the activities and the accuracy of the resident’s self-assessment skills.  Evaluations will be signed in ResiTrak following this discussion.

What type of evaluation

Who

When

Midpoint

Preceptor, Resident

End of week 2

Summative

Preceptor

End of learning experience

Summative Self-evaluation

Resident

End of learning experience

Preceptor, Learning Experience Evaluations

Resident

End of learning experience