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					                                       THINKING

PHRD 4300 Experiential Practice III                                  Below expectations

A 30 year old female presented in the OTC aisle. She actually approached me before I
could get to her. This patient had a very complicated situation that put my knowledge
and ability to the test. This was my first OTC visit and I was already somewhat nervous.

The patient was looking to treat stomach pain, possibly an antacid or laxative; she was
not sure. She felt bloated, completely full, had constipation, had developed hemorrhoids
from the constipation, had unexplained weight gain and breast tenderness.

Upon further discussion with the patient, I learned she had an Upper GI four-five weeks
ago and the results came back fine. However, she was still experiencing the above
unexplained symptoms. The patient stated that she had gained 14 pounds in the last week
and a half and asked if I have ever heard of false negative pregnancy test results.

I now had an abundance of information to digest and began asking questions. The first
question I asked this female patient was if she could be pregnant. She said she could be
but had two recent negative home pregnancy tests. She further explained that her mother
was five months pregnant with false negative results and had three miscarriages before
she gave birth to herself and her sibling. I asked if she had seen her gynecologist recently
and she said she had about 3 months ago and all was fine.

I inquired about the patient’s diet, water intake, alcohol use and exercise habits. Her diet
and exercise habits were not very good. I conveyed to the patient that the only OTC
product I felt comfortable recommending to her was a fiber product. She stated she had
Benefiber at home but was not using it. I explained to the patient that the product had to
be used with lots of water, specifically one 8 oz. glass with the product and at least 7
more throughout the day. I told the patient it could take up to 3 days for the fiber product
to begin working. I also suggested that the patient increase her intake of fruits and
vegetables and offered suggestions of spinach, beans, and dried plums, apples with the
skin and increased whole grains, maybe oatmeal for breakfast with fruit. I also suggested
walking for 30 minutes a day. I recommended that the patient schedule a visit with her
gynecologist and possibly seek a second opinion from a gastroenterologist if she was in
fact not pregnant. I stressed how important it was for her to contact her physicians before
doing anything else.

I meet expectations in thinking because I had a huge multi-faceted scenario presented to
me and was able to calmly, knowledgeably and thoroughly counsel the patient on her
options and have her leave the pharmacy feeling very pleased about all of my
recommendations and suggestions. She stated that she would make an appointment with
her doctors and that she would change her diet, try the fiber again and drink more water.
She would also walk the dog longer to get more exercise. I discussed this course of
action with Blake, the pharmacist now on duty, and he thought my suggestions were
appropriate and safe.
Comment: The student has done well but the statement is graded “below
expectations” because he/she has omitted a required element. The student has not
included reflective thoughts about he/she might have further improved if given the
opportunity to go back in time and re-counsel the patient. For example, the patient
stated she gained an unusually large amount of weight in a short time. The student
accepted that fact but, given the opportunity to reflect, might have wondered if the
weight gain was reported accurately. For example, the patient may have used two
different scales and the calibration on one might have been poor. The student
should be congratulated for his/her skill in counseling the patient but the statement
should not be accepted as “meets expectations” until he/she revises the work to
include the required reflection.

PHRD 4300 Experiential Practice III                                  Meets expectations

I met expectations for the thinking competency when I assisted an older woman and her
family, look for a pain reliever. She was at the grocery store with her son and daughter.
The daughter was pushing her mother up and down the OTC aisle in a wheelchair. They
stopped in front of the pain reliever section. I approached the group and asked if I could
help them. The daughter told me that the mother was looking for a pain reliever. I then
turned to the mother to ask for what sort of pain she was having. The mother responded
that she was “achy all over”. “I think I’m getting a cold,” she said. “I always start to feel
this way when I’m getting a cold”. Her daughter then pushed the mother back down the
OTC aisle and parked her in front of the cold medication section. I followed them and
again turned to the woman in the wheelchair and asked what sorts of symptoms she was
having. She responded again that she was feeling “achy”. I asked if she was aching in any
particular area and she said, “No”. I was trying to determine if she had pain in her legs
and if that was the reason she was in the wheelchair. So I asked if she had any medical
conditions. She again responded, “No”. Then I asked about cold symptoms, “Do you
have any congestion, runny nose, or fever?” She responded, “no”. I asked if she had used
a pain reliever in the past when she felt this way. She said that she had used Advil and
that it had worked fine. “Great,” I said, “the Advil is over here.” I showed her the
different dosage forms and she liked the gel caps. She decided on Advil 200 mg gel caps.
I asked her if she drinks alcohol and she again responded with a “no”.

This competency meets expectations for thinking because I continued to ask direct
questions to find out exactly what problem the woman wanted to treat. The daughter kept
wheeling her mother back and forth in the wheelchair without really knowing what the
mother needed help with. I also think I met the competency for thinking when I asked if
she had used something in the past, for these symptoms, that had worked for her. The
mother ended up leaving the store with a product that had been effective for relieving the
same symptoms in the past.

If I could repeat this interaction I would have asked if she had previously experienced
stomach upset with Advil. I could have added an additional counseling point about this
side effect. Maybe I should have asked her directly why she was in the wheelchair. The
reason I didn’t, was because I was trying to be respectful of her right to privacy and
balance that with trying to determine whether it would be pertinent information in
suggesting a medication. That is why I asked about a specific area of pain. In the end, I
think I should have asked directly. It may have given me additional information helpful
in treating her pain. Also, if I could repeat this interaction, I would have informed the
woman and her family that King Sooper’s gives flu shots. I could have given them
information about a convenient location to get a shot. If they decided to come back for
one, it would have provided a way to follow up and see if the pain reliever worked.

Comment: the statement “meets expectations” for PHRD 4300 (Experiential
Practice III). The student ended up giving good advice (use what worked for similar
symptoms in the past) but there’s evidence that there is room for improvement in
his/her counseling skills. For example, the patient gave one-word answers to many
of the student’s questions. Feedback should be given to the student that many
patients don’t understand the need for questions like “do you have any medical
conditions” and a little explanation can go a long way to getting patients to open up.
Educating patients that non-prescription medications may worsen disease states
(e.g., hypertension, diabetes and peptic ulcer disease, etc) is likely to make them
more forthcoming.

PHRD 4300 Experiential Practice III                                 Exceeds expectations

A statement that meets or exceeds expectations for PHRD 4350 or 5300 (Experiential
Practice IV or V)

PHRD 4350 Experiential Practice IV                                  Below expectations

A statement below or meets expectations for PHRD 4300 (Experiential Practice III)

PHRD 4350 Experiential Practice IV                                  Meets expectations

I met expectations for thinking competency when I counseled a patient looking at a multi-
symptom cold remedy. She accepted my offer of help and I asked her to describe her
symptoms to me (an open ended question to avoid leading the patient). She said she had
a runny nose, her eyes itched and watered, and she had a cough. In response to further
questions she told me that she’d had the symptoms for approximately two weeks, there
was no fever, and the cough was worse at night. I told her that the choice of OTC
medications can be influenced by other medications and by medical conditions and she
told me that she had high blood pressure. She had a product in her hand and I told her it
wasn’t her best choice because it contained pseudoephedrine and might raise her blood
pressure.

I met expectations for thinking competency because I helped this patient find an
appropriate product for her symptoms. I used thinking skills to decide she was probably
suffering from allergies and not a cold. The duration and nature of her symptoms (e.g.,
itchy eyes) suggested an allergy rather than a cold: the cough was probably due to post-
nasal drip as evidenced by worsening cough at night. I recommended Claritin as a
medication that would help with the runny nose and itchy, watery eyes, and dry up her
post-nasal drip to stop her cough. I told her the instructions were to take one tablet a day,
and that she should return to the pharmacy in 7 days for further advice if the symptoms
hadn’t resolved and earlier if the symptoms worsened.

This demonstrates improved thinking over last semester because I wouldn’t have been as
confident as I was to decide that the cause of the symptoms was an allergy rather than a
cold. I also remembered to ask the patient about pre-existing medical problems and I
didn’t always remember to do that last semester. I could have improved the counseling by
working with the patient to try to identify the allergen(s) responsible for her symptoms
and to offer non-pharmacological advice to minimize her exposure to the allergen(s).

Comment: this statement meets expectations for PHRD 4350. The student has used
thinking skills to differentiate between potential causes for the patient’s symptoms
and has explained his/her thought process. A student in PHRD 4300, faced with the
same case, might well have referred the case to his/her preceptor rather than
making an independent decision and taking that decision to the preceptor for
approval.

Feedback should acknowledge the student’s progress towards independent thinking
and decision-making. He/she, in terms of further improvement, should be
encouraged to be more explicit in subsequent writing assignments. For example,
what advice can be offered to minimize exposure to allergens?

PHRD 4350 Experiential Practice IV                                    Exceeds expectations

A statement that meets or exceeds expectations for PHRD 5300 (Experiential Practice V)

PHRD 5300 Experiential Practice V                                     Below expectations

A statement below or meets expectations for PHRD 4350 (Experiential Practice IV)

PHRD 5300 Experiential Practice V                                     Meets expectations

I met the competency for thinking when I helped a lady I came across searching for
something she couldn’t find. I introduced myself and she said that she was looking for
Allegra. I asked her if she meant Claritin because a lot of people who took Allegra by
prescription are switching to OTC Claritin, but she said her doctor told her to use OTC
Allegra. I told her that I wouldn’t be surprised if Allegra would soon be over-the-counter
but that it was still a prescription-only product. She was an elderly lady and she
proceeded to tell me that her doctor had told her last week that it was available over-the-
counter. I reiterated the fact that it was not yet OTC, and she persisted by saying, “Well,
it’s been a week already since he told me that. Are you sure it hasn’t come OTC yet?” I
knew that she probably didn’t have any concept of the length of regulatory affairs
processes, so I decided to try another approach with her. I explained that the conversion
of a drug from prescription status to OTC status takes a very long time, and that although
I wouldn’t be surprised to see Allegra on the OTC shelf in the future, it would be quite a
while until that happens. I directed her towards the Claritin and explained that it was in
the same class as Allegra, and asked if she had ever tried Claritin. She replied, “That’s
not Allegra, that’s not what my doctor told me to get.” She was proving to be a tough
customer and I tried another approach. I asked her “What symptoms are you trying to
treat?” She said that she had a constant runny nose, that the Benadryl she’d bought made
her want to take a four-hour nap every afternoon, and that she’d called the doctor to see
what to do. I told her that I agreed with the doctor for not asking her to make an
appointment and recommending an OTC product. But unfortunately, he/she must have
gotten mixed up as to which product was OTC and which one was still by prescription
only. At this point she looked like she was coming around, but still not convinced. I
asked her if she had insurance that covered prescription medications, and she said she
only had Medicare. I explained to her that a prescription for Allegra would cost about
$60-70 for a one-month supply, where for only about $19, she could get a month’s supply
of the generic Claritin, still only have to take the medication once daily, and have the
convenience of purchasing it over-the-counter. I told her it was worth it just to try, even
if she only bought a small box to see if it worked for her. I told her there was a very low
chance of it causing any drowsiness and that most people don’t complain of that at all. I
told her she shouldn’t have to worry about afternoon naps with this choice and that she
wouldn’t have to remember to take it multiple times a day like Benadryl. She agreed to
try it and thanked me for spending so much time with her.

I met thinking competency because she had been mis-informed and I had to delicately tell
her that I knew what I was talking about. At multiple steps in our conversation, I had to
think of different ways to convince her to try Claritin. This was an improvement from
last year in that I was too “agreeable” last year, and when a patient seemed to be set in
their ways, I wouldn’t try to change their mind. I was pleased at the end of the
conversation that she thanked me and recognized the effort I’d put into helping her. I
could have improved this interaction by asking her to call the doctor to confirm the
information I had given her, so that she could have the peace of mind to know that the
information I gave her was satisfactory, and to know that she had her doctor’s “blessing”
with my recommendation.

Comment: the level of competency demonstrated in the statement meets
expectations for PHRD 5300 though the writing preceptor may demand more time
and effort go into the reflection before accepting the statement. The student has
been persistent and demonstrated the ability to think of multiple strategies to
convince the elderly patient. A student in PHRD 4350 would in all likelihood have
asked their preceptor for help if faced with the same situation. However, the
reflection is superficial. Students in PHRD 5300 are expected to systematically
review the interaction from start to finish and establish multiple ways to improve.
For example, the student did not establish if the patient’s runny nose was a short-
term problem (cold?) or a long-term problem (allergy?). In addition, the patient
implied she might be paying large amounts for prescription drugs (reference to
“only” Medicare insurance) and the student could have offered to review her
medication profile with a view to reducing drug expenses. Students in PHRD 5300
should demonstrate the ability to extend interactions with patients beyond the
patient’s initial agenda. Feedback should recognize the student’s competency and
encourage him/her to seek out challenging patients to counsel as a means to further
develop their counseling skills.

PHRD 5300 Experiential Practice V                                   Exceeds expectations

Every pharmacist has the opportunity to be a role model. Role models incur significant
responsibility but not every individual realizes the depth of that responsibility. A
pharmacist that I worked with for a long period of time was someone that I trusted and
admired for their dependability, hard work, and professional skills. This pharmacist was a
role model and an individual I always looked forward to working with until recently
when I arrived one morning and had to wait 30 minutes past the normal opening time for
the pharmacist to arrive. When the pharmacist arrived, he/she was frazzled and appeared
disoriented (I was concerned he/she was under the influence of a drug). After a short
period of time he/she became more collected yet seemed a bit different than usual. I
confronted the pharmacist and asked if he/she was okay. His/her response was that things
had been stressful and overwhelming lately, but everything was under control. I was
disturbed by the events that occurred that day and followed up with the manager and my
fellow employees. I learned of the pharmacist’s constant tardiness and that others had
observed strange behavior. Patient safety and welfare was my immediate concern and it
prompted me to report the incident. I had a difficult time deciding what course to take
considering my previous respect and admiration for this individual. However, I have
professional and personal responsibilities to uphold and so do they.

I met expectations for thinking when I had to critically analyze the situation and make a
decision based upon my education, beliefs and ethics, without regards to my personal
relationship with this individual. This was the most challenging aspect of my career thus
far. I think this demonstrates improvement because, in the past, I probably would have
avoided this situation and expected someone else to take responsibility for solving the
problem. I have become more conscious of my professional responsibility to the
community and colleagues. I believe that I handled this situation professionally and the
only aspect I might change in the future is to first approach the pharmacist more directly
about the situation.

Comment: this statement exceeds expectations for PHRD 5300. It is unrealistic to
expect all students in PHRD 5300 to have the thinking skills to deal with this or
similar situations. The statement demonstrates that multiple competencies are
required for pharmacy practice: it could have been used to demonstrate several
other competencies. Feedback to the student should recognize his/her developing
skills and remind him/her that the writing preceptor is a mentor and that he/she can
be approached for advice.

				
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