Part II In A Series

Three months into their P-4 year, Interactions caught up with Ahmad Al-Rawi, Regine Caruthers, Julie Dumond, and Nikhil Patel, the four PharmD students being followed through the final stages of their University of Michigan College of Pharmacy journey.

When interviewed in August, all four had probable career paths in mind. At the end of October, Al-Rawi, Dumond, and Patel were still leaning in the same direction they had been. Caruthers, however, was having second thoughts about her intention to pursue a career in retail pharmacy.

“My clinical experiences have definitely muddied the waters as far as my career plans are concerned,” Caruthers confides. “My rotations with [Associate Professor of Pharmacy] Sally Guthrie and [Clinical Assistant Professor] Simon Cronin on U-M Hospital’s psychiatric and bone marrow transplant units were remarkable, not only for what I learned, but also for the privilege of seeing such dedicated people in action. You can’t help but be inspired when you are around such people.

“Dr. Guthrie’s rotation totally reshapedmy perspectives on mental illness. I had a basic academic understanding of mental illness going into my rotation, yet when you work with patients who are struggling so hard to hold on to their lives and identities, or see how mental illness in one family member can affect everyone in the family — you begin to grasp how devastating these illnesses can be. I was surprised to see how prevalent mental illness is among the elderly, and the clinical skill it takes to sort out symptoms of mental illness from age-related diseases. You cannot walk away from such experiences, unchanged.”

But what really altered Caruthers initial career plan was her rotation at Sinai Grace Hospital in Detroit.

“I was attracted to clinical pharmacy, but not the long hours and the ‘all or nothing’ demands that I had seen elsewhere,” Caruthers explains. “Then, at Sinai Grace, I met fully functioning clinical pharmacists working regular shifts that allowed them to have a family life, and other, non-work-related interests — both of which are priorities for me. I may still choose a career in retail, but if I have any expectation of following a more clinical route, I have to take steps toward a residency, now, even if I don’t ultimately pursue that course.”

For Al-Rawi, each rotation has offered a different lesson, only some of which had to do with the mastery of clinical facts.

A lesson in professional integrity was particularly pertinent for Al-Rawi, who aspires to work in the marketing department of a pharmaceutical or biotechnology firm. That lesson came during a meeting with a pharmaceutical sales representative while Al-Rawi was on a drug information rotation with Clinical Associate Professor Burgunda Sweet, RE’87, in U-M Hospital’s Department of Inpatient Pharmacy Services.

Sweet invited Al-Rawi to sit in on the sales meeting so he could learn the finer points of vendor relations. During the meeting, the sales rep was trying to persuade Sweet to endorse adding a new drug to the UMHS formulary.

“The rep claimed that UMHS was paying more, per unit dose, for a competing drug than a comparable drug offered by the firm she represented,” Al-Rawi remarks. “I had done research on the product before the meeting, and I knew the rep was distorting the truth. I told her that — politely, of course, and, I confess, a little reluctantly because even though I knew the facts, I was second-guessing myself.”

As it turned out, Al-Rawi was correct, and the rep toned down her rhetoric. Sweet later congratulated Al-Rawi on doing his homework, encouraged him to trust his judgment more often, and not to be afraid to take a stand when he felt he was right.

“Dr. Sweet’s support really boosted my confidence,” Al-Rawi says. “The experience also taught me something else: that if I am ever in a position where I am selling a product, I should stick to the facts, not make my case by disparaging a competitor. Distorting the truth only undermines your professional credibility.”

The incident that had the biggest emotional impact on him, however, was his first experience with the death of a patient.

“I was on my first rotation — a surgical ICU rotation precepted by [Clinical
Assistant Professor] Dr. Michael Kraft [PharmD’99],” Al-Rawi recalls. “I had been assigned to three patients, one of whom was an elderly lady with end-stage renal disease. One day, her vital organs started shutting down, one after another. I was with the attending physician at her bedside when she died. I watched as he pulled a sheet over her face and walked away. I just stood there, stunned at the finality of that act, and at the fact that modern technology, with all its wonder drugs and technical sophistication, could do nothing more.

“Dr. Kraft saw me struggling. He explained that on an ICU, we are always dealing with the sickest of the sick; that there are 20 beds on the unit, most of them occupied on any given day. He said that while we can and should be affected by the death of a patient, the ones who are living are counting on us to care for them. We must always remember that.

“I learned so much from Dr. Kraft about the physiology of diseases and the mechanisms of the drugs used to treat them, but what he taught me about professionalism are lessons I’ll never forget.”

Patel, too, came face-to-face with a patient’s death while on rotation in an emergency department. But for Patel, it merely confirmed his ultimate goal to be a physician.

His ER rotation had been less than he hoped for because, as he says, “there really wasn’t a direct role for a pharmacist in the ER I was assigned to. We would have lectures and discussions on various topics each morning, but the afternoons, which were spent in the ER, were uneventful. I finally asked my preceptor if I could switch to the night shift with the hope of having different experiences. She approved the plan, so I started going in between 9-10 p.m. and staying until 4-5 a.m.”

Early one morning, Patel walked into the trauma room with a code in progress.

“The patient was in her mid-80s, and I watched as they inserted lines and started CPR. One of the medical residents working on the patient turned to me and said, ‘Are you a medical student?’ I said no, I’m a pharmacy student. He said, ‘Are you interested in this?’ I said I wouldn’t be here at 2:45 a.m. if I wasn’t interested. So he said, ‘Okay, grab some gloves.’ They asked me if I had ever done CPR, and I said only on a practice dummy, never a real person. The residents guided me through the CPR. They helped me place my hands as I did chest compressions for about 10 minutes, and explained the vital responses I should be aware of. They then had me conduct manual respiration using a handheld squeeze bag attached to the patient’s face mask for another 10-15 minutes while they monitored responses and lines.

“We got a heartbeat initially, but the patient eventually passed away. I was nervous and excited the whole time, but at the end of the experience, I was ecstatic at what had just taken place. I never imaged that I would have this opportunity as a pharmacy student,” Patel says. “I thanked the resident afterward for giving me an opportunity to try to help save a life. He said: ‘Whether you go to medical school or not, you now know how to do CPR on a real person. That’s valuable in itself.’

“That experience in the ER only reinforced my desire to go on to medical school,” Patel says.

While Dumond’s rotations may have lacked the drama of Patel’s, they offered plenty of other learning experiences. From Kenny Walkup Jr., owner of Specialty Medicine Compounding Pharmacy, she absorbed valuable life lessons.

She also discovered that, despite her initial misgivings about clinical rotation in the cardiology clinic at U-M Hospital, a good preceptor can make learning even difficult material enjoyable.

“I got through the cardiology material we covered in class, but it wasn’t one of my favorite subjects,” confides Dumond. “My cardiology rotation with [Clinical Assistant Professor] Dr. Daniel Streetman changed all that. He is an outstanding teacher who took a lot of time with us to make sure we understood the material. His capacity to make the subject interesting and exciting not only helped me understand the drugs used to treat cardiovascular conditions, but also how to get the most out of patient interviews, and how to work smoothly with other members of the medical team. Dr. Streetman also taught us the relationships between drug therapies and other treatment modalities. We did a lot of work with evidence-based medicine, so I’ll have a much better ability to analyze and evaluate trials and papers, which will make me a more discriminating clinician. I never thought I’d say this, but the whole area of cardiology now fascinates me.”

The rotation with Streetman had another salutary effect on Dumond, whose career plans include a residency and employment as an academic pharmacist.

“You learn good teaching skills by being around good teachers,” Dumond says. “If I do have the privilege of teaching pharmacy students someday, I will model my own teaching methods after those of Dr. Streetman.”.