I've always been more of a right-brain type of person. In middle school my siblings opted to do sports, I dropped out and joined a creative writing club instead. I drew, painted, sketched, wrote and crafted my way through elementary, middle and high school thinking I'd perfect my photoshop abilities, pick up skills in coding and become a graphic designer when I grew up. Clearly, that never happened and I ended up on the complete opposite of the job spectrum. But wait. Why do we usually think of science and art as being two totally separate fields?

When I started pharmacy school I lost my drive to create. While I'm sure exams, and extracurriculars contributed, I ultimately blame myself for letting my first love fall by the wayside. I stopped finding time to doodle. I no longer wrote poetry. My paints were touched pretty infrequently. My life became pharmacy, pharmacy, pharmacy. Being focused on school is not something I regret but I do regret thinking that I could never possibly do both; continue to love the arts while also loving pharmacy. I started to realize how much I missed exploring my artistic side during my P2 year. In our College building on campus hangs the beautiful painting "The Gross Clinic" by Thomas Eakins:


After starting school and learning that this painting was of a doctor (Samuel Gross) at Jefferson in our old surgical amphitheater during the 1800s, it quickly became one of my favorite pieces of art on campus. In my P2 year it was temporarily taken down and I found myself hoping every day when I passed through the College building that it'd be put back up. It wasn't long before I realized just how much I was enthralled by that painting, and that my love for it made me nostalgic for the days I spent creating. So slowly, I started again.

I began to use my study breaks creatively rather than using them for social media. It started with just sitting out on my back porch and painting again. By P3 year I was writing again and was even able to submit a poem to our university's literary magazine. In the beginning of my 4th year I picked up brush lettering, a more modern form of calligraphy and used it to help me study.  And of course, I started blogging too! Then during my second APPE, I was introduced to my university's design curriculum included in the medical school's program.

My second block preceptor is co-director of this program and taught me all about using design thinking to solve healthcare problems over our six weeks together. I was floored by this concept and even more in awe of the projects the students in the program were working on. They were all working tirelessly on creative solutions to complicated healthcare problems, from stress ulcers, to hospital noise and wound care. I learned that the design thinking process consists of five principles: empathize, define, ideate, prototype, and test. If you think about it, thats not so different from the pharmacist patient care process: collect, access, plan, implement, and monitor/follow-up.

The idea that we can't be creative in our practice because we're pharmacists is entirely out dated. I believe we get creative every day and it simply goes unacknowledged to ourselves. We get creative with counseling the vast array of patients we care for, we get creative in drug shortages, we get creative in our continued learning, and sometimes in our care plans. Of course there's more! Since rediscovering my creative side and learning about the design thinking, I think about how design impacts us in healthcare every day. I think differently about the problems I encounter. Beforehand I may of thought that a patient who was non-compliant with their inhaler was just being difficult, but now I think of how the design of the inhaler really isn't formulated for compliance. Each inhaler has its own pearls, they aren't standardized, and many are not intuitive. Ease of use plays a big role in compliance. Fellow healthcare students, how often have you had a patient show you how they use their inhaler and its completely right? The number is probably small, but its not their fault! Once you start to see the problems and how they can be helped by better design you see them every where, even with the beloved prescription bottle!

Overall, I think rediscovering my art and being inspired by the work done at our JeffDesign lab has made me a better pharmacist. I think that actively acknowledging your creativity and bringing it into your practice enables you to empathize, and problem-solve in a way that is not accessible otherwise. So before you say "but I'm not creative", I'm going to call BS and insist that you pick up your paint brush anyway, doodle on your papers, start blogging or writing poetry. I think you'll surprise yourself and I think you'll like how it changes you.

Happy pharmacy week everyone! This is a week to acknowledge and appreciate all of the hard work, the love, and the dedication that pharmacists, interns and technicians pour into the profession. I for one have been lucky to study under amazing pharmacists, learn from incredible preceptors, collaborate with hard-working technicians, and grow with my insanely talented classmates. I'm going to start off this week with some insight into what I love about this profession and what I do every day.

1. Pharmacists are the most recognizable and accessible healthcare professionals in the community. We're also one of the most trusted professions. This enables us to tackle health literacy problems within the community head on and to provide education and counseling to our communities. Working in a community pharmacy for the last four years, I've seen my preceptor connect with our community and work to improve their health literacy. He has the uncanny ability to break difficult scientific concepts into a language our patients can understand and learn from. I've always admired this and it has definitely highlighted the impact community/ambulatory care pharmacists have on public health.

2. We improve patient safety and reduce drug errors. This one may seem self-explanatory but I've been consistently impressed by the diligence and attention to detail my preceptors have displayed. Our healthcare system is not perfect, and patient care can be really complicated. Having a pharmacist's eyes on the medications can be critical to providing the safest and most optimal care to our communities. I've been a part of many teams on my rotations who have welcomed the voice of the pharmacist for that exact reason. I've also been that voice a few times myself (team trying to add a beta-blocker to a patient with a heart rate of 32...can anyone say bradycardia!?). If we want the best outcomes for our patients its vital that pharmacists be included on all healthcare teams.

3. Our practice is expanding (exponentially)! Currently there is a push for pharmacists to have provider status. What does this mean? We're looking to be classified under Medicare Part B as providers, a status given to other healthcare professionals such as physicians, PAs, NPs, social workers and midwives. Without this designation we face barriers in compensation, coverage of services, and inclusion in ACA delivery models. Being granted provider status would allow us to help medically underserved communities and fill in the gaps in care.  Even more awesome, some states allow for collaborative agreements between pharmacists and prescribers to provide advanced patient care. It differs per state but this means that in some agreements we can provide intervisit care, titrate medications and order labs under a prescriber.

4. We're team players. I've been lucky enough to be surrounded by other healthcare professionals who love having us around, and I love having them to learn from! I've learned so much from MDs, DOs, NPs, nurses, PAs, social workers, dietitians, other students and MORE. I truly believe we are only as good to our patients as we are to each other. And its only together that we can hope to turn our healthcare system around and work cohesively to bring stellar, efficient care to every one.

This was brief but I hope ya'll got the big picture: we're awesome...and we do more than count by fives (age old assumption...never say this to your friendly neighborhood pharmacist). So this week, take the time to thank your pharmacist, your technicians and your interns (or you know, bring them a donut). We work hard to keep our communities safe, educated and healthy. And to my fellow pharmacy folks, enjoy the week!

P.S I made the above graphic/took this photo at the New Orleans Pharmacy Museum, a must-see for my fellow healthcare peers

My current rotation on GI has led me to observe patients with a range of diagnoses, namely inflammatory bowel conditions like ulcerative colitis and crohn's disease, irritable bowel syndrome, and neuroendocrine tumors. Although these diseases/syndromes are all incredibly different from one another, all who they afflict are subject to extreme GI-related anxiety. This is an anxiety I've known all too well during my entire life. During my first few days at the clinic I was shocked to hear some of the things I dealt with myself growing up and all through pharmacy school repeated from the mouths of the patients we saw. Feelings and thoughts I believed to be exclusive to myself were suddenly the same sentiments shared by other people. After seeing some of these patients and silently reflecting on our shared struggle, I decided to write a little bit about my experience with chronic illness and anxiety while in pharmacy school.

Pharmacy school is an emotional and physical challenge that can take a toll on both your mental and physical health. Therefore it never surprised me to hear about fellow classmates who had to deal with worsening or new onset chronic illness in the midst of their pharmacy school years. I used to feel immense sympathy for those who juggled doctors appointments around exams and struggled with just feeling well enough to show up to class. I felt immense sympathy until I became one of those people who couldn't fit in doctors appointments, who never felt well in class and who was too sick to focus on my education. When that happened, my sympathy turned into empathy.

In my P2 year, I dropped to 86 lbs. I had stopped eating full meals and relied solely on baggies of cheerios and the pre-packaged cheese/cracker boxes at Wawa. I avoided eating in public or with friends as often as I could. I was so nauseous every day that I had to plug my nose while walking by food trucks or be subject to dry heaving in public. I was constantly nervous about where the closest bathroom was, if I'd be able to leave class/rotation, and if i'd make it through the day without throwing up or passing out. This was me at my worst and it was years and years of denial in the making.

It started when I was 6 years old. An unfortunate accident landed me in CHOP's GI department with a colon so dilated it was a miracle I was able to function at all. As a little kid, I didn't have much of an understanding of what was happening but I knew the pain was intolerable and the medications just as bad. For a short period of my life I was able to ignore my illness and avoid preventing the subsequent pain and discomfort with medication. I'd go through pockets of being absolutely fine and it was like I was never sick. I never thought as myself as a person with a medical problem. But then the pain and sickness would come roaring back and I'd wish I was anyone but myself.

Eventually the episodes would present so intensely that I'd fear the next one. I'd stop myself from leaving the house if I felt the slightest belly twinge. I'd map out all the bathrooms, plan extensive escape plans, and make any excuse to drive myself so I wouldn't be stuck. If I knew I was going to be out for a night, I'd make sure I didn't eat just in case my stomach decided to descend into chaos post meal while I was still out. Eating meals out in public were almost always taboo unless it was one of my very few "safe foods" (soup, caprese sandwich, more soup).

It used to be that the anxiety would only linger for a short period of time after an episode finished, maybe a week or two. As I went through my college years, the periods of anxiety became longer and longer until I knew my anxious state better than my calm state. It became suffocating. When pharmacy school came around I was managing my GI-related anxiety and my GI symptoms as if they were this part of me that I had to accept as is. I didn't seek out additional treatments or professional help until my P2 year when after a bad break up, and a bad semester I was left an anxious set of bones. I was inattentive, distracted and in a lot of distress. I didn't even realize what was happening with my weight until I came home for the semester and one of my college friends said, "what is going on with you? You don't look well". A few days after that I got on a scale for the first time in years at a doctors appointment and was stunned to see myself about 15 lbs below my normal weight.

I wish I hadn't waited so long to seek out help. Had I known that making the time to go see a doctor would be the first step in taking control of my condition I would have felt better a lot sooner. I'm extremely lucky that despite my medical troubles I never fell behind in school, and my grades did not suffer. I know there are others who are not so lucky. So my advice is this:

1. Do not wait to seek help. If you're struggling, tell a teacher you trust, a doctor, or a friend. There is no reason to suffer in silence when there are people around you who have access to resources that can help you.
2. Advocate for yourself. That includes in school, in our crazy healthcare system, and in life. 
3. Remember that you don't have to prove anything to anyone. I constantly felt like if I didn't over-explain my situation to people that they would never believe me later when I needed to bail on something due to sickness. It took a while for me to realize that only I knew my condition inside and out and other people really don't have to for it to be real and valid.
4. Seek out accommodations. If your school has a process, use it! Even if you don't enact your accommodation in the entirety of your schooling, at least you have it just in case. It'll do wonders for your anxiety. 
5. People will understand more than you think they will. I've learned so much from sharing my story with classmates. You'll be surprised to learn how many people have experienced similar hardships. 

It is a genuinely good question. Aren't we just supposed to count by fives and verify medication orders until our eyes bleed? I realize that some of you, med students, PA students, nursing students and even some P1-P2 pharmacy students may not have exposure to pharmacist positions where we are more clinical on the outpatient side. And hey, thats okay! But I'm going to open your eyes a little bit today to what we do in that setting. During my time at Penn Center, a primary care facility in west Philadelphia, I've taken blood pressures every day, multiple times a day. I don't take them for the practice or to double check anyone, I take them because our attendings and residents rely on us to take them. You may think this is a rarity, or something total bizarre, but I'm going to tell you why it works and what exactly we provide for our attendings and residents.

At Penn Center, pharmacists conduct "intervisit" care. Essentially our patients are scheduled to follow up with their primary care doctors every 6 months or so (less or more depending on their problems and stability). However, we all know the work burden of attendings and residents and we all know that sometimes 6 months is too long but you just can't fit people in any earlier. Schedules are backed up, and in most internal med practices this would be where you'd have to default to fitting in phone calls between patients or just trusting your patient to call if there is an emergent issue. At our practice, pharmacists fill that gap. We provide free appointments to our patients during the interim where the patient is waiting for their doctors appointment. So maybe we see them 2 months out, or a few weeks out. Either way, they're not waiting 6 months or more for their next contact with a healthcare provider.

What do we do during these appointments? We handle what we know best: the meds. Our pharmacists have built an extremely tight bond between the attendings and residents at our clinic so they trust us completely when it comes to managing, titrating and adding new medications for chronic diseases. They refer many of their patients to us for teachings, for med management, and sometimes when the patient is so complicated with their regimen that they really just need a second set of eyes. Typically we handle hypertension, and diabetes the most as far as chronic disease states.

For our hypertensive patients we conduct blood pressure tests so that we can properly titrate blood pressure medications. We order labs, we order meds, and we get things done in the interim so our docs can focus on their patient and other non-med related issues during their appointments. I had a patient the other day who popped in for a blood pressure check 3 weeks after seeing his PCP. His blood pressure had been mildly elevated when he last saw his PCP but they had stopped one of his blood pressure medications  because the patient admitted to being non-adherent to all of them. So in order to avoid dropping him too low when he became adherent, we dropped one. 3 weeks later I'm performing an intervisit blood pressure check and I get a blood pressure of 200/100. I panic (inwardly of course) and I go for his other arm to verify. 200/110. After doing a quick symptom evaluation and then leaving (running) to go get my preceptor, we discussed a plan to present to his PCP who happened to be on site. His PCP was extremely grateful he had told him to come in for a BP check with us, agreed with our plan, and we developed a plan to get our patient out of hypertensive urgency.

For our diabetics we do the same: order A1cs and titrate meds to optimize glycemic control as much as possible. We also do insulin and GLP-1 pen teachings so our patients being newly initiated on injectables have the best chance of lowering their A1c by properly administrating the drug to begin with. Our attendings and residents love us for this because there are so many different nuances between pens and they simply don't have time during their appointments to take the 30 minutes to make sure the patient REALLY gets it. We also utilize these appointments for diet and exercise counseling too. Many of our diabetic patients see us for weight management and are extremely grateful we can take the time to talk to them in depth about their lifestyles and what they can do to change that A1c. It takes time, and we have it, so we free up the doc's schedules to see their other high risk patients for issues pharmacy can't handle.

My particular rotation is unique in that my preceptor also handles our refugee patient population and their latent tuberculosis treatment. As you probably know, initiating and finishing LTBI treatment is vital to preventing conversion to active disease and avoiding multi-drug resistant TB development. We initiate, and monitor treatment to ensure that our patients are adherent and safe. In fact, after implementation of the pharmacist-run LTBI clinic, our LTBI treatment completion rate at Penn Center tripled to 94%. That is 11% higher than the goal completion rate set by the CDC!

Now some other questions you might have: why don't the med students handle it? We have 1-2 med students rotating into the clinic. They see their own patients either separate of, or with the residents. They too usually don't have time to dedicate to intervisit care, med teaching and titration between didactic seminars and their own patient load.

What about nurse practitioners? We actually have two great ones! And us doing these intervisit sessions frees them up for drop-in hours! So they handle all of our acute patients who need to be seen right away.

Our medical assistants? They are AMAZING. But hey, we have a ton of patients to see so they have a ton of blood sugar sticks to do, heights/weights to check, prescriptions to organize and rooming to figure out. Plus, when they don't have to do blood pressure they're able to converse with the patient and let us know the chief complaint before we even waltz into the room (and that is a godsend).

This model works. Our attendings and residents are extremely appreciative to have us around and they are constantly recommending their patients to make appointments with us. I've been told numerous times by docs during my six weeks at this center how valued we are as pharmacists. We lessen the burden by just doing what we've been trained to do. Again, this may seem totally weird if your only experience with pharmacists has been through CVS or the basement pharmacy in the hospital, but in ambulatory care this is the norm. Our scope of practice is expanding nationwide at a time where people need help accessing care. In every state we have the ability to immunize. In certain states we have the ability to prescribe medications, which expands public access to care. We are forming collaborative practices with physicians where we prescribe, manage and titrate in states like North Carolina. As students we participate in community outreach events just like other healthcare students do. We are no longer solely tied to our ability to manage product, we are a service based profession. Having us around improves patient safety, medication error rates, and clinical outcomes. As one of the pharmacists at our clinic would say, "we are pharmacists practicing at the top of our license".

So yeah, we carry stethoscopes and they aren't just for show, we're an integral part of the team.

I decided to take a break from doing my antibiotic series of brush letter pharm to do a review of our glucose lowering agents instead. This short review will cover mechanism of action, side effects, weight effects and A1c lowering of our 6 big classes: Biguanide, DPP-4, GLP-1 agonists, Meglitinides, Sulfonylureas and TZDs (side note, it is very difficult to find consistent reporting of A1c lowering of these agents, I did my best to report generally what I've seen in most literature). And before you ask, yes, I left out insulin on purpose. I'll cover that sometime in the future. Enjoy!

Biguanides: Metformin
oral agent

• A1c lowering: 1-2%
• MOA: decrease hepatic glucose output, decrease glucose absorption and enhance insulin sensitivity. Work better on fasting blood glucose levels (FBG).
• Side effects: nausea, diarrhea, cramping, rare/life-threatening lactic acidosis esp. in patients with hepatic or renal impairment
• Effects on weight: neutral/loss

Sulfonylureas: Glipizide, Glimepiride, Glyburide
oral agent

• A1c lowering: 0.8-1%
• MOA: increase insulin secretion from pancreatic beta cells by regulating ATP-sensitive K+ channels. Have effects on both fasting and post-prandial glucose (PPG).
• Side effects: hypoglycemia, weight gain
• Effects on weight: gain

Meglitinides: Repaglinide, Nateglinide
oral agent

• A1c lowering: 0.7-1%
• MOA: Regulate ATP-sensitive K+ channels on pancreatic beta cells to help improve insulin secretion (same MOA as sulfonylureas, different binding site). Reduces PPG more than FBG.
• Side effects: hypoglycemia, weight gain
• Effects on weight: gain

SGLT-2 Inhibitors: Canagliflozin, Empagliflozin, Dapagliflozin
oral agent

• A1c lowering: 0.8-1%
• MOA: inhibit SGLT-2 in the proximal tubule of the kidney which prevents reabsorption of glucose and subsequently causes glucose to be excreted from the body through urination
• Side effects: hypotension, polyuria, yeast infections, UTIs
• Weight: loss

DPP-4 Inhibitors: Sitagliptin, Saxagliptin, Linagliptin, Alogliptin
oral agent

• A1c lowering: 0.5%
• MOA: Inhibits DPP-4, enzyme that breaks down incretin hormone GLP-1. Potentiating action of GLP-1 leads to increased satiety, slowing of gastric emptying (therefore decreased appetite), and increased insulin secretion through glucose-dependent matters. Reduce PPG more so than FBG.
• Side effects: nausea, otherwise generally well-tolerated
• Effects on weight: neutral

GLP-1 receptor agonists: Exenatide, Liraglutide, Lixisenatide, Dulaglutide
injectable agent

• A1c lowering: 0.8-1%
• MOA: Potentiate the action of incretin hormone GLP-1 which leads to increased satiety, slowing of gastric emptying (therefore decreased appetite), and increased insulin secretion through glucose-dependent matters. Reduces PPG more than FBG.
• Side effects: nausea, diarrhea, cramping
• Effects on weight: loss

TZDs: pioglitazone, rosiglitazone
oral agent

• A1c lowering:1-1.25%
• MOA: inhibits PPAR-y which encourages storage of fatty acids and utilization of glucose. Enhances insulin sensitivity. Works on both FBG and PPG levels.
• Side effects: fluid retention (can lead to acute decompensated HF), fractures
• Effects on weight: gain