A Taste of U.S. Pharmacy in Tucson (an exchange student's perspective)

This past summer my wife and I had the good fortune of hosting three foreign pharmacy students for a couple days.  Eventually, they made their way to Tucson, AZ for a two month training program.  One of the students, Luka Tehovnik, took some time to document his trip and graciously shared it with us in this blog.  Please feel free to comment at the bottom to support Luka and his colleagues in this fantastic adventure.

After being interested in International Pharmaceutical Students’ Federation’s Student Exchange Program (IPSF SEP) for quite sometime, I finally did it! I can confidently say that this past summer was the best one I have had so far! It’s difficult to describe the feeling when your dream of travelling to the United States of America finally comes true!

It’s unbelievable how time flies! Not so long ago I can recall myself and the student from Barcelona, Helena, sitting in a cozy Gentle Ben’s on E. University Blvd. in Tucson, Arizona, It was the first brewery in Tucson when it started operating back in 1991. Having their iconic “Tucson Blonde” beer I enjoyed conversation with two Local Exchange Officers (LEO), Douglas Lee-Chan and Wendy Wong and other students from the University of Arizona. We discussed topics from US and Slovenian pharmacy differences to the plans I had for this special experience. That was one of my first social evenings of my genuine American experience.

University of Arizona Medical Center

The University of Arizona Medical Center (UAMC) was the site where I spent most of my time. The morning of my first day at work I got to know my preceptor, pharmacy professor, Dr. Michael Katz with whom I had a fascinating conversation about the upcoming controversial Affordable Care Act (ACA) or so called “ObamaCare”. We also discussed the US and Slovenian health care system and pharmacy education differences, and the role of a pharmacist in both countries. Dr. Katz provided me with several articles about ACA; at the end, I had a clear idea of what ACA is all about and I was able to describe the Medicare Part D prescription drug program coverage gap, a.k.a. the “Doughnut Hole” phenomenon. The beginning of my shadowing experience was very educational, impressing me even more than I already was… I was hungry for more!

Later that day, I attended some lectures, presented by pharmacy residents. Residents are pharmacists who pursue a pharmacy education beyond the Doctor of Pharmacy degree (PharmD), which is required for licensing as a pharmacist in the US. I got to know the pharmacy residents and interns with whom I worked with during my shadowing experience at UAMC. Everyone was so delightful and I honestly couldn’t wait for my practice to begin.

On August 6th at 8 a.m. the real work started. I was assigned to a team at the Internal Medicine Department, which consisted of an attending physician, pharmacy and medicine residents and students. There were approximately 10 people in our group; imagine 10 people entering the patient’s room!

Since UAMC is a teaching hospital, I had an opportunity to meet and know a large number of pharmacy student interns. One of the responsibilities of pharmacy interns was to get to know the patients who would be visited on a specific day. They gathered relevant information from the hospital’s database, focusing on drug related information as well as other pertinent information. Their goals were to recognize potentially harmful drug interactions; stopping the medicine if it was no longer needed; starting the new medication; ordering therapeutic drug monitoring (TDM); recognizing possible noncompliance; and, in general optimizing existing drug therapy.

Presenting the patient’s medical history to the team was the same every day; it was the same routine on every ward I worked on. One from the team, usually a medicine resident or a student presented the patient in depth consisting of: their chief complaint, past medical history, comorbidities, blood tests, past and present treatments and other essential information regarding treatment. A discussion took place in front of each patient’s room, which we were to enter; after all information was clarified, we entered the patient’s room to acquire additional information from each specific patient. I should stress that pharmacy interns were actively included in conversations about the future treatment plan for patients, and doctors appreciated every concern that pharmacist (either a licensed one or a student) addressed to them whether it was a drug interaction, an inappropriate drug or just a drug which was no longer needed. An important aspect we always discussed was whether or not a patient had health insurance. Insurance is essential for reducing healthcare costs for the patient since a national health service does not exist in the US.

While in each patient’s room, attending physician asked the patient a series of questions about their health condition, feeling, possible improvements/deteriorations and drugs. The patient was presented with findings about a specific disease or syndrome and they were presented with a potential diagnostic and treatment plan.

During the ward rounds I completed my patients’ records with additional information, which I had gathered. If needed, at the end of rounds I would accompany a pharmacy intern to visit a patient or consult with a pharmacist with the goal of obtaining additional information.

I had the opportunity to observe the work of a pharmacist in 4 areas: Internal Medicine, Oncology, Intensive Care Unit (ICU) and Pediatrics Intensive Care Unit (PICU). I met different pharmacist on every floor who instantly assisted me with my questions and shared as much knowledge as possible in the time allotted. I especially loved the time I spent in the Oncology unit because in addition to rounds, I also had the opportunity to do additional tasks such as: witnessing lumbar puncture, high-dose methotrexate (HD-MTX) intrathecal application through the Ommaya reservoir (intraventricular catheter system) directly into cerebrospinal fluid, bone marrow biopsy and an IV cytostatic drug preparation. I am very grateful because I would never have been afforded the chance to do these things in Slovenia! I extend a special thanks to the doctors and pharmacists who made those things possible!

Every afternoon a group discussion was led by our preceptor, Dr. Katz. Each one of us presented a case which we found the most interesting and educational from different aspects such as disease complexity, other comorbidities and most importantly, pharmacotherapy. We discussed whether the drugs that were stopped or started were suitable or not; was a patient handled properly; and, what could be changed and or improved. I was included in each patient presentation and conversation afterwards and I tried to participate as much as I could. These meetings were very beneficial in terms of acquiring new knowledge about different drugs and their optimization, how to handle patients properly, promote a quick patient recovery and discharge from the hospital.

During my visit at UAMC I attended a myriad of seminars, prepared by physicians, pharmacy residents and students. These seminars included topics like poisoning and antidotes, a more detailed look at chronic diseases and pharmacotherapy, new drugs on the market and those drugs that are still a part of clinical trials. Following the presentations there was a topic discussion where all participants were encouraged to ask questions, which was another great way for acquiring new knowledge!

Main Differences

I participated in the team discussions about patient treatment plans; however, because of the significant difference between the educational programs in the U.S. and Slovenia, it was sometimes difficult. U.S. pharmacy is more clinical and focused on the patient, whereas in Slovenia, it is more chemistry/laboratory based. In Slovenia, studies are more concentrated into the discovery of new active substances and, consequently, new drugs rather than focusing on the patient. The Slovenian students have more lab exercises than the U.S. students. In my opinion, patient focus is not emphasized enough in my country. The U.S. pharmacist has a very important role in the hospital setting and their opinions and suggestions are taken seriously and usually accepted.

I like the U.S. system better; for example, in the state of Arizona, a pharmacy student is required to have 1500 hours of practice completed before they can apply for North American Pharmacist Licensure Examination (NAPLEX). Of course this number varies from one state to another but it is not all that different. When the U.S. students graduate, they have a clear idea where they want to practice their profession.

During my stay in the U.S., I was surprised to learn that customers can purchase alcohol and cigarettes in a pharmacy; no such pharmacies are found in Slovenia. Convenient stores like Walmart, CVS/Pharmacy, Costco and Sam’s Club have pharmacies located within their stores. Therefore, patrons can shop for food, clothing and Over the Counter (OTC) medicines while waiting for their prescription to be filled; you would never see this practice in Slovenia. In my opinion, the pharmacy should be located by the exit door in order to provide the customer with more opportunities for specific counseling regarding drug usage and contraindications in order to prevent poisoning or overdose. For example should a customer purchase Tylenol for a headache and another pain medicine for ankle that contains acetaminophen there would be a possibility for an overdose. Additionally, in the U.S. there are TV commercials where OTC and prescription drugs are frequently advertised; the advertisement of prescription only drugs is illegal in Slovenia.

While at UAMC I had an opportunity to attend a lecture presented by my preceptor dr. Katz regarding pharmacotherapy of asthma and chronic obstructive pulmonary disease. It was interesting to note that almost every student had a laptop, which is not common at my faculty.

An Authentic American Experience

During the month I spent in Tucson, AZ, I had a variety of experiences ranging from hiking in Sabino Canyon to a live gunfight show in the city of Tombstone, eating delicious food in typical American restaurants and attending house parties. Social activities were well organized and I was able to see a large part of a very spread out big city of Tucson!

I spent two marvelous months in the States and I must say in spite of a lot of misconceptions about the American people, they were amazing! Maybe it was that I hung out with the best people or maybe it was just my positive attitude. Either way, before being judgmental, I suggest you pack your things and go there. I think you will be pleasantly surprised!

While in Arizona, I had a chance to observe health care professionals performing their job and I tried to absorb as much information as I could. It became clear to me how important pharmacists really are! I learned and saw a lot and had high expectations; my experience ended up being more than I had hoped for! The exchange enriched me professionally, culturally and personally. My confidence has been boosted, pharmacy knowledge and various skills improved, including the ones regarding proper patient interaction. I was so impressed by the work of clinical pharmacists, my area of interest, and by amazing people who surrounded me that I really wanted to stay there! I am working hard towards that goal.

I would recommend SEP to everyone; it’s an opportunity of a lifetime, which should not be missed! It’s a perfect way to establish a professional and social network, which can enhance success. If you want to experience pharmacy on another level in other countries, then this is exactly for you!

In summary, I would like to thank the LEOs, Douglas and Wendy, for locating a place to stay, and also to Katrina, Lisa, Matthew and other students who helped with organizing different activities. Furthermore, I would like to extend a big thanks to my preceptor Dr. Katz who did his best to make my experience as great as possible, and also to the pharmacy residents, floor pharmacists and other healthcare professionals who accepted me in their midst for a short period of time. I felt like part of the team!

Lastly, I give a whole-hearted thank you to my dear host family, Dr. William Jones, his wife Anita and their children Amanda, Scott and Helen for making my time great, unforgettable and providing me with everything I needed. Thank you for lending us your car, for delicious margaritas, meals and the quality time I spent with you! I didn’t feel alone not even for a second and I didn’t feel homesick! Thank you again for making me feel like part of your family... I will never forget what you did for me!

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Medication Information Destination

The other day a patient came into the store complaining of white patches on her tongue and a dry, chalky taste in her mouth.  My partner was working with her and he said, after a discussion with her, that she had been using her new steroid inhaler now for over three weeks without rinsing her mouth with water after use.  Furthermore, because of this, she had recently stopped using her long acting steroid inhaler and had gone back to just using her short acting rescue inhaler.  

Upon further discussion, my partner understood that the patient had not received any counseling about her new prescription when she had picked it up at a big box pharmacy a few weeks ago.  No one had counseled her about how to use the inhaler, what side effect or monitoring parameters to look out for, how to use it in relation to her other medications, or any of the other many important aspects of the medication that should be covered in a face-to-face counseling session with your pharmacist. 

This patient was having severe shortness of breath and wheezing from asthma induced by a respiratory infection and her doctor had prescribed a steroid inhaler to help reduce the swelling and inflammation in the airways of her lungs.  There are many important topics to discuss when counseling a patient about their new steroid inhaler; however, at a minimum, a patient should never leave the store without understanding the importance of rinsing their mouth out with water following the administration of a steroid inhaler dose.  

Community pharmacies are much more than just places you go to pick up your prescriptions.  Among other things, I like to consider the community pharmacy a Medication Information Destination.   Yes, while you are at the pharmacy you will pick up your prescription; however, equally as important, you will pick up your medication information.

When you walk into your big box pharmacy, stand in line for 10 minutes and then pick up your prescription, do you also leave with your appropriate medication information.  Does your pharmacist take the time to meet you in the counseling area and discuss all of the important counseling aspects of each medication with you?  If the is medication is a refill, will your pharmacist ask you how you are doing with it and if you have come up with any questions since you last came into the store?

Quite often, the answer is yes, the pharmacist is allowed appropriate time for medication counseling.  If the answer is no, then take some time on a free afternoon, visit four or five local pharmacies, interview the pharmacist for a couple minutes, and choose a pharmacy you feel comfortable with.

I understand that many insurance companies require patients to fill their prescriptions through mail-order pharmacies in order to get the best pricing; however, does your mail-order pharmacist call you each time they send you a new prescription in order to discuss all of the OBRA 90 mandated pharmacist counseling information?  If you have questions, do you need to call the mail-order pharmacy and wait for a pharmacist to come to the phone in order to ask your questions?

I encourage patients with mail-order plans to call their insurance company and request the option to use their own community pharmacy.   Quite often, just a simple phone call is all it takes for an insurance company to allow a patient to pick up their prescriptions at a local community pharmacy.

Remember, each and every prescription has its own set of monitoring parameters, side effects, interactions and unique counseling information associated with it.  Your community pharmacy is your own personal Medication Information Destination.  Not only do you pick up your prescriptions from your community pharmacy, you also take home with you, from your counseling session with the pharmacist, all of the important information necessary in order to optimize your therapy with that particular medication.


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Opiate Pain Therapy, Tolerance and Strategies

What prompted the increase in opiate prescribing over the past 50 years, why do we develop a tolerance to opiates, and what are some solutions to the situation?
·       1991 to 2009, prescriptions for opiate pain medications increased almost threefold, to over 200 million per year.

·       Prescriptions for opiate pain medications nearly doubled, from 11% of all prescriptions in 2000 to 19% of all prescriptions prescribed in 2010.

·       The United States makes up only 4.6 percent of the world's population; however, consumes 80 percent of its opiates.

·       Prescription opiate medications were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined.

·       Deaths from unintentional drug overdoses have risen fivefold since 1990.

Read the article at RxEconsult:


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