Inpatient Medicine: How to Survive and Conquer

My inpatient medicine rotation was so challenging, but in one of those amazing ways where you learn a ton in a short period of time. I’ll be honest and say I didn’t do too much prep for this rotation, because I wasn’t really sure what to expect. The first two weeks I was rounding on general surgery (I’ll talk more about this in another post), which was much more relaxed than the medicine floor and gave me time to adjust. For those of you getting thrown right into internal medicine this post should be very helpful.

First, let me explain a little more about what I was responsible for on my rotation and what a typical day looked like, because everyone’s APPE experiences are truly so different. When I was on the medicine floor, I was expected to round with a medical team every morning as the soul representative of pharmacy, my preceptor was never with me. I got to the hospital each morning around 6:45am, rounds started at 7:30am, so this gave me some time to look over patients beforehand. Rounds ended somewhere around 10-11am depending on how many new patients we had. My responsibilities for each patient included: medication reconciliation, DVT prophylaxis, renal dose adjustment, antibiotic stewardship, vaccines, drug interactions, IV to PO, drug info questions from the team…the list could go on and on, but those are what most of my time was focused on. After rounds, I would go complete my two med recs, enter in my interventions, follow up on any questions or medication changes necessary, and counsel patients. At some point I would find time for lunch, even if that was at 3pm. In the afternoons before leaving, I met with my preceptor to go over patients or do scheduled topic discussions.

As I have talked about a little before, Yale monitors your medication reconciliations and your interventions on a weekly basis. Everyone is expected to do 2 med recs a day or 10 a week and then the other interventions are simply how many interventions you were able to make on your patients. 

As you will see, each patient you encounter is different from the next and they require different amounts of attention. One patient could be relatively healthy with an acute DVT which you need to start treatment for and then send home, and the next patient could have a bacteremia secondary to a diabetic foot ulcer that needs an amputation followed by an intense course of IV antibiotics. With that being said, I worked up most patients the same way each morning. 

How I Work Up Patients

New patients:

  • I record the patients initials, sex, age, weight/BMI, and creatine clearance 
  • Do they have a med rec yet?
    • If not then I flag it for myself to do that day
  • What medications are they currently on? Including:
    • Do they have DVT prophylaxis? 
      • If not, I ask the team to add either Lovenox or Heparin based on the patient’s CrCl
    • Are they on antibiotics?
      • If so, what is it treating, do we have cultures and what day of therapy is it?
    • Are they on medications that require specific monitoring? For example:
      • Warfarin: monitor INR daily and adjust dose accordingly
      • Vancomycin: check dose, determine if/when troughs should be drawn, follow up on trough levels and change dosing as necessary
    • Did all their important home meds get continued?
      • If not why and should they be continued? (Maybe the patient has an AKI)
    • Are they due for any vaccines?
      • Pneumococcal vaccines are most commonly indicated

Patients already on our service:

  • Is their CrCl today stable, better or worse?
  • Were any medications added or discontinued?
  • Antibiotics
    • What day is it, do we have cultures/sensitivities back yet, can we deescalate therapy?
  • Daily monitoring of specific drugs
    • Warfarin, Vancomycin, etc
  • What is their overall plan/are they being discharged today?

By the time I get this done for all of our patients, it is normally time to round. I use my iPad during rounds to continue to look through the patients profile and deal with checking for renal dose adjustments, IV to PO, drug interactions that were apparent upon my first glance of their meds and I handle any drug info questions my team asks. 

My biggest pieces of advice:

Do NOT be afraid to say you don’t know or that you need to double check on something. I have been asked so many questions that I didn’t know the answer to. This is nothing to be ashamed of. The whole point of rotations is to learn and the other pharmacists or medical staff you are working with certainly do not expect you to know everything they ask you. The best thing you can do in this situation is to look it up, use it as a learning opportunity and get back to your preceptor or medical team the next day with the answer. 

Learn the DVT prophylaxis dosing and creatine clearance considerations for lovenox and heparin. Pretty much every patient in the hospital will need DVT prophylaxis and it is good to be familiar with the dosing for your specific patient or why you have to use a certain agent and not the other.

Speaking of anticoagulants, being familiar with warfarin and DOACs is huge. Most hospitals have pharmacists handle warfarin dosing and the DOACs are so new that most providers aren’t that comfortable with them either. I answered so many questions for my team on DOACS (including doing a formal teaching session) and I handled all our patients warfarin adjustments. The team was happy it was one less thing they had to worry about and I was happy to be directly impacting patient care. 

Antibiotics…so so many antibiotics. Luckily, my preceptor and I did a week long antibiotic review near the start of my rotation. But even after that I had to keep refreshing myself because there is just honestly so much to know on this subject. I found that the most important things to be familiar with on the inpatient medical floor was: what agents cover MRSA and pseudomonas, how to treat CAP vs HAP, bacteremia, and treatment for diabetic wounds/ulcers.

Lastly, I will say that this is rotation is a huge opportunity to grow as a future pharmacist. On all rotations it is important to seize opportunities, even if you are slightly scared or uncomfortable, that only leads to growth and more experience. I loved volunteering to counsel patients on new medications like warfarin or DOACs, even new inhalers (which I hated doing in school). I also jumped at the opportunity to talk to patients about their uncontrolled diabetes. Especially if they were in the hospital due to a complication of diabetes, it was very important to me to make sure they understood diabetes in general and why all of their medications were so important, etc. In general, I love interacting with patients, I don’t find it intimidating at all, but it was something that really stood out to my medical team and preceptor as a great strength of mine. Counseling patients is a huge part of being a pharmacist, so if you aren’t comfortable with this try to make doing this a priority on rotation. 

Teaching my medical team about DOACs was another great experience for me. Presenting in any manor tends to make me nervous, but again this is something I am going to encounter a lot so I might as well get better at it. My medical team was great and it was a good way to practice my skills. Although it was a requirement, I also had a formal presentation at the end of my rotation. I did mine on MRSA bacteremia. Making the actual presentation challenged my primary literature skills, which was desperately needed (I hated drug literature in school but I think I should have paid more attention). I ended up presenting in front of 5 pharmacists, 1 internal med resident, 5 pharmacy students, and my medical team…the student a week before me had to present to maybe 5 people total. One of the pharmacists also happens to be my future MICU preceptor. To say this was the most intimidating presentation was an understatement, but guys I crushed it. I spoke loud and confidently the whole time and knew everything I had researched in order to handle all questions they asked me and felt so great at the end…it was a MAJOR win in my book. 

I hope this post helps you get ready to conquer internal medicine and get a major win in your book as well. As always, please please please message or comment any questions you have and good luck my pharmily!!! 

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