Day 4: Shadowing

This is my last day of shadowing. I went to Dr.Traina's office in the Diabetes Center today. She had two students there Anne and Matt. When I first came I went right to Dr.Traina's office but had a surprise waiting when I saw a patient was in there with someone I didn't recognize. It turned Matt was taking care of a patient while Dr.Traina was overseeing Anne meeting with another patient. So I sat a bit in the waiting room after texting Dr.Traina to let her know I was there. When Dr.Traina did come out she led me back to her office where Matt was still with the patient and told to wait outside. As I watched from the door the interaction between Matt and Dr.Traina made me think back to all the times I had a student teacher. Matt was taking over the patient's visit like how student teachers take over a class for a day. After the patient had left Dr.Traina explained that Matt and Anne were on their second week with her in the office. At this point she said they were supposed to start to become independent so that she could work without needing to look over their shoulders. I watched Matt and Anne write up their notes.  After seeing a patient it is required to write notes which contain what was discussed, for which doctor or nurse practitioner does the patient belong, and if a patient needs to come back why. Matt wrote this down but Anne had to write a additional part since she changed the medicine doses the patient was on. Dr.Traina would give pointers while watching them. One interesting advise she gave that if there is time in a visit to get to know the patient so they are more compliant to listen to you. They were learning to use a program called CareConnect which is the computer system that contains all the patients' information. Before the students saved their notes Dr.Traina would check them to make sure they are not too wordy or not specific enough. After typing up her notes Anne left to go to the library which is really just a room with one computer and some shelves of books. Dr.Traina called back a patient who she missed the call of that morning about calcium pills. The patient wanted to take less of these pills but Dr.Traina said he couldn't because he has a very serious case of pagets disease of the bone. This is when bones turn over and re-form too quickly so the bones are weak. This particular patient had it in large bones so he had to take the dose of pills he was on. After the call Dr.Traina typed up a note about it. Dr.Traina left to get her laptop which left just me and Matt. Matt made a call to a patient telling her to bring in all her medications for her next visit. Matt and I talked a little bit. He apparently knew a few Thomas teachers and Mr.Armstrong from Spry. Both Matt and Anne are on their last year of pharmacy school he told me. Last year students have to work in a office for their last year like Dr.Traina's. When Dr.Traina came back she had Matt email a nurse practitioner, Jane, about a patient who had to lower doses of one of their medicines, a blood pressure medicine, due the bad interaction it was having with her other medicines. But now the blood pressure medicine isn't as effective so Matt emailed Jane to let her know of this. Both Matt and Dr.Traina made a few more calls to patients. Anne came back from the library. The three hours went by rather quickly and before I knew it was time to go. This is the end of my shadowing. It leaves me with a lot to think about when it comes to my career choice.
The board of famous people with diabetes in Dr.Traina's office is below.

Day 3: Shadowing

I was at St.John Fisher for my third day of shadowing. Dr.Traina and her students met for journal club. They presented three articles. I was reminded of my first day of shadowing with the packets they used to present. Dr.Traina explained that all the students had read the articles but that each student had to pick from the articles to analyze one. All the articles were about a new form of medicine and a study conducted to see how effective this new medicine is. The first article was on insulin pumps and it was called Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes. The purpose of the study was to show that insulin pumps can help improve glycemic control in both adults and children when compared to multiple daily insulin injections. So basically this study was to find an easier and more effective method insulin management for people with Diabetes type one. The study was done on those between seven and seventy years old. Three months previously these patents' daily injections were looked and seen the insulin levels so the glycemic control before were known. Patients who had used a insulin pump in the past three years, used pharmacological non-insulin diabetes treatment in the past three months or were pregnant were excluded from this experiment. There were improvements seen but more in the adults than the children. The presenter decided this wasn't a very good study due to it having more weaknesses than strengths. The insulin pump was changed from the Telemetered Glucose Monitoring System to the MiniLink transmitter. Most of the patients in the study were white. The presenter also found a potential bias in the study due to the data being sent to the sponsor Medtronic, who designed the insulin pump studied. This was the process all the presenters went through there was obviously more in depth information with calculations of hemoglobin Alc levels which in the simplest explanation Dr.Traina could prove is what is used to measure the average glucose concentration. Dr.Traina also drew a pictures to explain the way the insulin pump works which is basically there is a part connected to a person's side that when sugar levels are starting to get low transmits from the sensor to little machine to warn the person that sugar levels are getting low. The other two articles presented were Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy and Apixaban versus Warfarin in Patients with Atrial Fibrillation. The first one was a study to test whether adding extended release niacin to statin therapy would reduce the risk of cardiovascular events as compared to statin monotherapy in patients with low HDL levels and small,dense particles of LDL. This was when things got more complicated. The students tried to explain HDL and LDL but although I understood when LDL particles are small and dense are bad I didn't catch much else. So I went online and looked them up. I found that they are different kind of cholesterol. Cholesterol is a soft, waxy fat particle produced by the liver that circulates in the blood. I was on the right track with LDL. LDL stands for low-density lipoprotein and it is what is considered the "bad" cholesterol. HDL stands for high-density lipoprotein and it is considered the "good" cholesterol. So low levels of HDL is bad and can be caused by a generic predisposition, lack of exercise, smoking or obesity. Statins are a class of drugs used to lower cholesterol as the students and Dr.Traina explained. The difference between statin therapy and statin monotherapy is that statin monotherapy uses just one drug while statin therapy is more then one drug. So after going over this study the weaknesses still outweighed the strengths but the not by much. Weaknesses were over 85.2% were men, 92.2% were white and the study was ended too quickly. There wasn't much of a change in any levels with the addition of niacin but if longer there might have been a different result. The strengths were a large number of patients were part of the study and there were no major differences in characteristics between the two study groups. The last article presented compared two drugs, apixaban and warfarin, which both are used to thin blood to prevent strokes. The strengths outweighed the weaknesses in this one. In fact the presenter found only two weaknesses that there was no consort diagram, to see difference in results, and the patients taken out of the study halfway through were not accounted for. There was also sponsorship bias like mentioned with the first article. So day three of shadowing was overall informative. But I am starting to lean away from pharmacy and back to chemical engineering my original career choice. But for now until next time.
Dr.Traina's drawings she used to explain the insulin pump and the readings range it gets are below.

References:
http://www.healthcommunities.com/high-cholesterol/overview-of-high-cholesterol.shtml?c1=GAW_SE_NW&source=GAW&kw=what_is_ldl_and_hdl_cholesterol&cr5=11655462945

Shadowing: Day 2

 On  my second day of shadowing I went to Dr.Traina's office in a diabetes center on 224 Alexander Street, Rochester in suite 200. I watched her daily activities and asked questions. She basically spends her time getting emails about problems with drug doses and bad reactions to a drug. So she has to figure out what is causing these problems. Some days she said patients come in and she finds out how things are going in person. But for my time there she looked at information from emails. Once looking at the problem and who the patient Dr.Traina would then look up that person's medical files on her computer. One woman reported having constipation. She had diabetes type two, high blood pressure, plaque in her arteries where five metal pipes were in place. Her report said she was taking iron pills but that she had stopped about a month ago. Dr.Traina then called the patient and put her on speed dial so I could hear the conversation. The patient explained she couldn't go and then Dr.Traina found out the patient was also taking about three doses of colace which Dr.Traina explained to me was a very powerful drug that a small amount, definitely not even close to as high as three doses, should make a person go. Dr.Traina suggested the patient take miralax instead which is stronger so the patient wouldn't have to take as high of a dose. After asking the patient more questions we also found out she was taking calcium pills. Dr.Traina looked like she wanted to do a forehead smack here. Apparently that there is this acumen FeCAL that is used to remember too much iron, calcium, or aluminum cause constipation. The woman though said after feeling the medicine wasn't working she stopped taking calcium but that it was recent. So Dr.Traina recommended the patient come in to get blood work done to find her current calcium level. The next patient Dr.Traina looked at was a mentally disabled middle age man. Now this was an interesting one. The man was scared of needles apparently so Dr.Traina said he didn't taken his insulin unless forced. So she called the nearest pharmacy to ask what he has been taking out. He had taken out some of his diabetes medicine but he hadn't done that in over two months. He did take out sleeping pills though. His average blood sugar Dr.Traina looked up was three hundred thirty when the healthy amount is around one hundred. This clearly showed he didn't take his insulin. This patient was a mess. He reported consistent headaches and he doesn't eat regular meals. When Dr.Traina tried to call him the phone number he gave was out of service. She had to go to the file room where she found conflicting files. One said he was married while the other said he was single. The other number she found did ring but it went to voice mail. He has had several visits due to high blood pressure and as Dr.Traina concluded cannot understand consequences. So Dr.Traina said she'll have to ask a home where mentally disabled people live to take him in. After Dr.Traina has come up with a solution for each patient she has to fill out a sheet with overview report to put on that patent's chart. From my day with Dr.Traina I came up with key traits a pharmacist should have. They must be friendly and patient, a good problem solver and improviser, and be able to multitask. They also have to know their stuff. When a problem occurs they should everything possible about the drug and other drugs that serve the same function.