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Course Approval
Phar 4690: ONCOLOGY Clerkship
SYLLABUS
Course Title: Oncology Clerkship
Course Description: A formative clerkship to develop clinical skills with patients in adult oncology clinical settings including: adult medical oncology, Bone Marrow Transplantation, hematology and chemotherapy order processing and preparation.
Course Number: PHARMACY 4690
Team Leader 1:
Brad L. Stanford, Pharm.D, BCOP
Phone: (806)743-4200, ext. 228
Fax: (806)743-4209
brad.stanford@ttuhsc.edu
Team Leader 2:
Sachin R. Shah, Pharm.D.
Phone: (214) 372-5300, ext 230
sachin.shah@ttuhsc.edu
Team Members:
Mehdi Arzaghi, R.Ph., MS
Southwest Cancer Center Pharmacy
806-775-8600 ext 31461
marzaghi@teamumc.com
Clerkship Coordinator:
Loree Allen
School of Pharmacy
1300 Coulter, Rm. 206
Amarillo, TX 79106
Phone: 806/356-4000 Ext 306
Fax: 806/356-4018
Email: loree@cortex.ama.ttuhsc.edu
Daily Schedule: Inpatient Services: Site specific
Required Textbooks: Pharmacy 4690 Clerkship Manual
Pre-Requisites: P4 standing as per Student Credentialing Committee.
Catalog Description: Pharmaceutical care experiences with patients having oncological diseases.
Course Philosophy (Mission): The mission of this clerkship is the development of the candidate's knowledge and competence with providing clinical pharmacy services to adult oncology patients.
- This includes providing the student with a broad experience, primarily in inpatient oncology including a combined hematology/oncology service, exposure to outpatient oncology in a regional cancer center, and a stem cell transplant unit (Lubbock only).
- Students are expected to round on the inpatient team on a daily basis and provide pharmaceutical care services to the oncology team including drug monitoring, admitting drug histories, patient assessments of pain, nausea, and other supportive care functions, drug information, and attendance at weekly tumor board.
Tech's Top Ten:
Upon completion of this course, the candidates shall have practice and assessment in:
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COMMUNICATION
1.1 General Communication
Competency Definition: Pharmacists affect patient care and the delivery of health care using timely, efficient, and appropriately targeted communication skills. Communication skills provide the foundation for patient - pharmacist relationships as well as relationships with other health care providers and payers.
The P4 clerkship student shall be able to:
- present (both orally and in written format) a therapeutic issue or concept with confidence and independent proficiency to patients, fellow health care providers, and the lay public.
- develop presentation skills by delivering inservices to other health care professionals and the health care team by adapting content to the level of the audience.
- demonstrate good human relation skills.
- consistently, accurately, and succinctly relay drug information to patients and colleagues
- recognize their knowledge and experience limitations ("I don't know, however, I will investigate and give you a call.")
1.2 Communication in the Patient or Caregiver Interview
Competency Definition: Conducting and recording a thorough patient interview (medical history and medication history) enables creation and implementation of a drug therapy related problem list and pharmacist's care plan.
The P4 student shall be able to:
- conduct and document a thorough patient interview that includes the following components: chief complaint, history of present illness, past medical history, social history, family history, and medication history (e.g. prescription medications, drug therapy related devices, nonprescription medications, alternative therapies including herbals, vaccination history, drug and food allergies.
- create a patient work up of drug therapy related problems.
- create a drug therapy related problem list.
- effectively interact with patients who are cognitively or physically impaired ( e.g. interviewing proxies and caregivers).
- communicate an educational message to a patient appropriate to a selected clinical situation.
- communicate with a patient or patient's agent at an appropriate level.
1.3 Patient Education
Competency Definition: Enhancement of a patient's knowledge and understanding of medical care and related drug therapy related plans will improve patient compliance and translate into improved patient economic, clinical, and health outcomes.
The P4 clerkship student shall be able to:
- interview the patient or caregiver obtaining information necessary to assess the need for additional information, education, and counseling.
- provide written patient information in a form that the patient can understand.
- identify, analyze and use commercially available patient information monographs.
- create patient information monographs.
- provide oral consultation concerning the patient's medical care in a manner the patient perceives as empathetic, tactful, and appropriate.
- prepare written patient information that is appropriate to the needs and educational level of the patient within a specific healthcare institution or community.
1.4 Written Communication [Documentation]
Competency Definition: Documentation of pharmacy services is an essential activity. Documentation in pharmacy practice includes activities such as: writing a SOAP note in the medical record, providing written pharmacotherapeutic consultations, maintaining required prescription and patient profiles, and submitting proof of pharmaceutical services to third party payers. All documentation is written. Pharmacy services, which are not documented, are considered as never occurring.
The P4 clerkship student shall be able to demonstrate:
- proficiency in providing succinct and accurate patient-specific information related to drug therapy management.
- the proper procedures for generating pharmacist's notes to be placed in the patient's legal medical record.
- the ability to document patient care in a manner which supports reimbursement for pharmacists' activities beyond dispensing pharmaceuticals.
- confidence regarding the information / knowledge provided by providing such notes in the patient's pharmacy/ medical record.
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USE OF BASIC SCIENCE
- Accurately perform pharmacokinetic calculations and adjust drug therapy accordingly.
- Demonstrate knowledge and assessment of the therapeutic goals and/or endpoints.
- Demonstrate the ability to manage disease states and adverse drug reactions with appropriate therapeutic monitoring.
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PROBLEM PREVENTION AND SOLVING
- Identify, define, and present a solution to a drug therapy related problem while on the inpatient oncology service.
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DISPENSING OF PHARMACEUTICALS
Competency definition: Pharmacists perform a unique "safeguard" role in health care by consistently assessing the appropriateness of doses so as to avoid both supertherapeutic and subtherapeutic doses. A pharmacist's mathematical abilities are combined with knowledge of pharmaceutical products and their delivery to create systems approaches to ensuring safe and appropriate doses. The calculation, preparation and assessment of parenteral and nonparenteral doses are central to the pharmaceutical care process in all practice settings.
The P4 student shall be able to:
- define the normal dose and number of dosage units for any drug product (prescription and nonprescription) used in any of their patient's regimens.
- calculate the appropriate dose for any drug product using mathematical skills and mathematical reasoning.
- provide the reasoning behind commercial and noncommercial dosing charts and confirm the accuracy of dosing charts. 4. recognize both supertherapeutic and subtherapeutics doses.
- adjust doses based on patient specific parameters such as renal or hepatic dysfunction.
- convert doses based upon different dosage forms of a pharmaceutical product.
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PROVIDING PHARMACEUTICAL CARE TO INDIVIDUAL PATIENTS
5.1 Providing Individual Patient Care
Competency Definition: Pharmacists base their clinical decision making on an understanding of the most common disease entities. Therefore, students must learn the most common disease states encountered in each clerkship course (e.g. pathophysiology, diagnosis and diagnostic studies, clinical laboratory medicine, treatment regimens, and monitoring parameters) and apply this knowledge to direct patient care.
The P4 clerkship student shall be able to:
- demonstrate an understanding of the pathophysiology, clinical presentation, diagnostic studies, treatment and monitoring of those disease states specified in individual clerkship course manuals.
- apply knowledge gained from previous coursework to individual patient care.
- demonstrate the ability to create and assess an appropriate pharmacotherapeutic regimen using knowledge gained from coursework in pharmacology, pharmaceutical care, pharmacokinetics, dynamics, pharmacotherapy, and practice management.
- integrate knowledge of the basic sciences to differentiate among pharmacologic agents within the same class.
5.2 Patient -Care Plans
Competency Definition: Central to provision of patient care is creation of a pharmacist's care plan. The major steps in care plan creation, implementation, and modification include: data gathering, patient assessment, care plan formulation/implementation, modification of care plan and implementation of a follow-up plan. Communication of the care plan to the patient and other health care professionals is fundamental to improving patient health care outcomes.
The P4 clerkship student shall be able to:
- accurately and efficiently locate information in the medical chart or other records and apply this information to patient care.
- demonstrate effective data gathering skills and be able to report this data in an organized and concise format.
- identify both active and potential drug-related problems.
- integrate both objective and subjective patient information in the development of the patient care plan.
- assess, evaluate, and apply drug information/clinical data to promote optimal health care for an individual patient and for patient populations.
- develop a pharmacotherapy plan complete with alternative solutions to treat, improve, and solve drug related problems.
- implement a rational pharmacotherapy plan and follow-up for an individual patient.
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PROVIDING PHARMACEUTICAL CARE TO LARGE POPULATIONS
- Demonstrate the role of the oncology pharmacist within the inpatient oncology population paradigm.
- Identify the cost versus benefits for high-cost supportive care medications in the oncology population and determine their impact on the overall healthcare system.
- Demonstrate ability to document clinical pharmacy services in an appropriate manner.
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MORAL REASONING, ETHICAL AND LEGAL JUDGEMENT
Competency Definition: Pharmacists should conduct their professional and personal lives in accordance with a set of moral principles and values. These principles govern pharmacists' individual and collective group activities. Professionalism entails adherence to moral, ethical and technical codes of conduct as well as supporting the entire body of persons committed to the pharmacy profession.
The P4 clerkship student shall be able to:
- Establish and maintain professionalism within all practice settings.
- Demonstrate the ability to develop and maintain ethical standards in pharmacy practice.
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MANAGEMENT SKILLS
Competency Definition: All pharmacists require practice management skills regardless of their specific practice setting or orientation. Frontline practicing pharmacists must participate in planning, organizing, leading and controlling organizational resources in the pharmacy environment. They may be responsible for demonstrating the outcomes of their practice to supervisors, other health care providers and payers. Other pharmacists may assume a more direct management role of technicians, other pharmacists, and operations.
The P4 clerkship student shall:
- demonstrate time management skills.
- identify the appropriate costs and benefits for any set of alternatives to a given action or program initiative.
- identify the cultural differences among patients and the impact these differences have on the delivery of pharmaceutical care.
- describe the patient outcomes of a pharmaceutical intervention and develop a methodology to measure those outcomes
- describe the operation aspects of pharmacy practice setting: staffing model deployed, systems of drug distribution, reimbursement strategies, methods of financial control, methods of quality management.
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ADVANCING THE PROFESSION AND PROMOTING HEALTH
- Demonstrate the ability to define patient interest on the inpatient oncology service.
- Demonstrate the ability to define the general interest of the profession of pharmacy in an inpatient oncology service.
- Demonstrate the ability to perform as a role model.
- Demonstrate the ability to influence colleagues.
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PERSONAL GROWTH
Students will demonstrate characteristics of personal growth through 1) independence, 2) initiative, and 3) life-long learning.
Independence. One of the primary aspects of independence will be the demonstration of independent learning skills, as shown in preparation for patient care and clerkship assignments. An important aspect of independence is demonstration of appropriate flexibility in delivery of pharmaceutical care.
Initiative. The student shall demonstrate self-motivation. Some of the qualities seen in the individuals will be the ability to work to their personal and professional limits while taking responsibility for patient care, outcomes, and other clerkship assignments. The student shall be able to understand when to question the statements of others and appropriately gather information related to these statements (e.g., not accepting the statements of others as gospel, but rather independently verify these statements by consulting appropriate references). The student will demonstrate independent initiative by delivering pharmaceutical care to their personal and professional limits and consulting with others when the situation is beyond those limits.
Lifelong learning. Students shall demonstrate the desire, even the thirst for knowledge, a commitment to continuous, lifelong learning. They should be able to learn in a self-directed manner, investigating new situations presented to them in the delivery of pharmaceutical care. The student must acknowledge personal responsibility for continuous, lifelong learning.
Composite Competency Definition: Pharmacists should demonstrate comfort, effectiveness, and efficiency in the independent initiation of clinical decision-making and appropriate consequent action in dispatching the functions associated with the delivery of pharmaceutical care, in accordance with valid therapeutic judgment, ethical practice, and sound management principles.
The P-4 clerkship student shall demonstrate the ability and initiative to:
- be a self-starter.
- function as an independent, in-depth learner.
- make independent judgments.
- carry-out the functions of the contemporary pharmacist independently.
- evaluate the judgments of other health care providers independently.
- initiate self-assessment.
- initiate an ongoing process of self-education.
- self-educate independently.
- initiate interdisciplinary cross-talk.
- initiate a comprehensive planning process.
- initiate appropriate change.
- initiate appropriate intervention.
Additional Competencies
ACCOUNTABILITY
Competency Definition: Pharmacists fulfill multiple responsibilities simultaneously. Central to all pharmacists' responsibilities is self- accountability to ensure that responsibilities are fulfilled to the fullest extent, within the expected time frames, and appropriate follow-up mechanisms are created, implemented, and monitored.
The P4 clerkship student shall be able to:
- place the care of patients above all other responsibilities.
- perform patient care functions in a punctual and professional manner.
- ensure that all patient care functions are performed prior to leaving for the day.
- provide optimal care for patients so that practice accountability will be applied to patient care post graduation.
- understand a pharmacist's role in patient care and be accountable for the provision of pharmaceutical care to patients
- learn to prioritize and complete the multiple responsibilities of a health care provider.
TEAMWORK
Competency Definition: Teamwork is work done by several associates with each doing a part, but, all subordinating personal prominence to the efficiency of the whole. Pharmacists function as an integral component of a team whose ultimate goal is to provide the best patient care possible.
The P4 Clerkship student shall be able to:
- function effectively within the team to optimize patient outcomes.
- communicate effectively within the team.
- handle an appropriate level of responsibility within the team.
- interact appropriately with different members of the team (e.g. pharmacists, patients, caregivers, physicians, medical students, nurses, therapists);
- sacrifice personal gain for the good of the team and its patient.
LITERATURE EVALUATION AND APPLICATION
Competency Definition: Pharmacists should consistently exhibit leadership in providing drug information using multiple state-of-the-art resources for both patient-specific drug therapy and system-wide drug therapy issues (e.g. creation of clinical practice guidelines or formulary backgrounds).
The P4 clerkship student shall be able to:
- demonstrate the ability to make rational, patient-specific therapeutic decisions, based upon critical evaluation of the literature and clinical experience.
- locate and analyze literature to solve a therapeutic dilemma in a timely fashion.
- make a recommendation to health care colleagues or a team.
- display the ability to find and accurately disseminate medical information through formal and informal presentations, discussions, and written communications.
- develop a personal method of staying current with the medical and pharmacy literature, including development of a filing system and/or a "peripheral brain."
INTERPRETATION AND APPLICATION OF PHYSICAL ASSESSMENT DATA
-- This competency may not apply to all sites and will be considered a site specific competency.
Competency Definition: Interpretation of physical assessment data and its application to creating and modifying drug therapy regimens is fundamental to pharmacy practice. Students shall incorporate physical assessment data into the provision of patient care and initiation, modification, and monitoring of drug therapy regimens.
The P4 student shall be able to:
- demonstrate skill in identifying and interpreting results of general and targeted physical exams (performed by any health care practitioner). apply physical exam data to the initiation and modification, and monitoring of drug therapy regimens.
Teaching Methods: This experiential course will be delivered in practice settings where students will provide clinical services under the supervision of pharmacy practice faculty / preceptors.
OVERVIEW OF EXAMINATION SCHEDULE AND ASSESSMENT METHODS:
Assessment tool developed by the faculty will be used in evaluating all of these activities.
Grading:
| Activity | Percent of Grade |
|---|---|
| Professional Performance | 55% |
| Educational In-service | 10% |
| Final Exam (written and/or oral) | 20% |
| TSBP Intern-Clerkship Evaluation | 15% |
| Total | 100% |
ATTENDANCE IS MANDATORY AT ALL DISCUSSION SECTIONS
It is the responsibility of the candidate to see that the assignments are turned in on time.
The approximate timeline for preparing and turning in written assignments will be as follows:
| Activity | Timeframe |
|---|---|
| Professional Performance Evaluation | by the end of week 6 |
| Inservice Presentation | by the end of week 6 |
| TSBP Internship Competencies (Initial) | start of rotation |
| TSBP Internship Competencies (Midterm) | by the end of week 3 |
| TSBP Internship Competencies (Final) | by the end of week 6 |
Descriptions of each of the aforementioned assignments and the grading criteria for each one will appear later in the clerkship manual.
NOTE: NO CREDIT GIVEN FOR ASSIGNMENTS TURNED IN AFTER THE DUE DATE.
Intellectual Integrity: Standard
Attendance: Standard
Class Timeliness/Tardiness: Standard
48 Hour Turnaround Policy: Standard
Second Chance Policy: There is NO second chance policy regarding this clerkship. If a student fails this course, they must retake it at the next opportunity when it can be rescheduled.
Etiquette: Standard
Clerkship Confidentiality: Standard
Name Tags and Professional Attire: Standard.
Candidate Disability: Standard.
Ethical Standards: Standard
Facilities: Standard.
Candidate Inquiries: Standard
Communication: Standard
Autobiographical Data Form: Standard
Immunizations and CPR Certification: Standard
Removal From Practice Site: Standard
Maternity Notification: Standard
Exposure Reporting: Standard
Candidate Professional Leave Policy: Standard
Inpatient Oncology Rotation (PHAR 4690)
Course Mission: The mission of this clerkship is the development of the candidate's knowledge and competence with providing clinical pharmacy services to adult oncology patients. This will build on the candidate's basic knowledge set from the Oncology Pharmacotherapy Course (PHAR 4264) from the P3 year. The candidate will receive exposure to a wide variety of tumor types in various patient populations, including geriatrics. The Lubbock campus also houses a stem cell transplant unit; therefore the candidate will receive experience caring for patients with multiple and complex drug therapies in that setting. Finally, the student will receive extensive experience in addressing various supportive care issues that typically arise in patients with cancer.
Objectives:
- Recognize multiple problems in drug delivery to oncology patients including venous access, gastrointestinal status, performance status, and laboratory values.
- Provide pharmacokinetic dosing and monitoring for patients on aminoglycosides, vancomycin, cyclosporine, and tacrolimus.
- Identify and provide pharmaceutical care and recommendations for supportive care problems in the oncology patient including:
Febrile neutropenia
Mucositis
Extravasation
Cancer Pain Management
Chemoprotectants
Chemotherapy-Induced Emesis
Hypercalcemia of Malignancy
Hematopoietic Growth Factors
Graft-Versus-Host Disease (GVHD)
Erythropoietic Agents
- Understand relevant laboratory values and diagnostic tests in the oncology patient including:
Renal function
Liver function
Anemia panels
Iron studies
DIC panels
Coagulation studies
Cyclosporine levels
Tacrolimus levels
Aminoglycoside levels
Vancomycin levels
Bone marrow biopsies & aspirates
Tissue sampling and biopsies
- Understand the pathophysiology and pharmacologic management of the oncology patient with hematologic/oncologic disorders or procedures including, but not limited to the following:
Breast cancer
Non-Hodgkin's lymphoma (NHL)
Non-small cell lung cancer (NSCLC)
Hodgkin's disease
Small cell lung cancer (SCLC)
Testicular carcinoma
Prostate cancer
Allogeneic stem cell transplantation
Colorectal cancer
Autologous stem cell transplantation
Acute myeloid leukemia (AML)
Chronic myeloid leukemia (CML)
Acute lymphocytic leukemia (ALL)
Chronic lymphocytic leukemia (CLL)
Multiple myeloma
- Identify various pain syndromes and delineate between visceral, somatic, neuropathic, & bone pain and develop and monitor a therapeutic plan for a given patient. The student should be familiar with the WHO cancer pain ladder, opioid dosing conversions, and the proper use of adjuvant agents.
Course Expectations (site specific)
The student will be expected to provide pharmaceutical care services to the oncology team under the supervision of the faculty preceptor. Students will participate in assigned topic discussions; however the course will be customized to the interest and knowledge base of the students in terms of content. Certain topics will be mandatory discussion items, however if the student has a particular interest in a certain oncologic disorder or supportive care issue, those can be addressed on an individual basis.
- Student Participation in Clinical Oncology Pharmacy Services:
- Attendance on inpatient oncology rounds with the oncology team (site specific)
- Participation in outpatient oncology clinics (site specific)
- Attendance at oncology grand rounds (typically monthly)
- Meet with preceptor to discuss patients, typically on a daily basis
- Provision of pharmaceutical care services on the oncology service, including:
- Monitor drug therapy on all patients on service including but not limited to;
- Clinical status and medications to identify potential drug interactions, adverse events, allergy problems, and pharmacokinetic / therapeutic considerations
- Design and recommend an appropriate drug-dosing regimen for an agent based on pharmacokinetics, therapeutic index, and patient-specific parameters
- Select and recommend monitoring parameters to assess therapeutic and toxic effects of an administered drug
- Evaluate and provide assistance with adjustments to drug therapy given potential therapeutic adverse events
- Develop alternative treatment plans when and if the original plan fails/proves toxic
- Locate and provide medical literature to provide patient specific information to health care professionals or families.
- Provide written/verbal information to health care professionals and/or families.
- Provide appropriate recommendations for procurement of drug levels
- Provide formal/informal education to medical staff, nurses, and patients and families regarding drug therapy
- Participate in interactions with patients and parents by counseling and taking drug histories.
- Document clinical interventions in the medical record.
- Document clinical interventions in a computerized database.
- Assist the clinical faculty member with ongoing clinical research projects and DUEs
- Topic Discussions on items listed on page 21 in the elective oncology clerkship manual will occur on a weekly or twice weekly (site specific) basis. Three binders containing relevant articles and guidelines are available in 1C162B on the Lubbock campus. These articles and guidelines should be reviewed by each student prior to the designated topic discussion period.
- Journal club discussions with the preceptor may take place on a weekly basis (site specific). The article will typically be assigned by the preceptor for the student's review. The student should be prepared to discuss and critique the study and determine its impact on current treatment paradigms in oncology. The following journals may be utilized:
Journal of Clinical Oncology
Annals of Oncology
Journal of the National Cancer Institute
British Journal of Cancer
Blood
Cancer
European Journal of Cancer
Supportive Care in Cancer
Journal of Pain & Symptom Management
Seminars in Oncology
- An in-service on a relevant oncology topic or new oncology or supportive drug will be assigned by the faculty preceptor for presentation to the oncology nurse staff and/or oncology team (site specific).
- Formal drug information questions as they arise should be researched and presented in a manner consistent with a drug information service at the discretion of the faculty preceptor.
Student Instructions:
- Throughout the Rotation: Students should create a systematic self-study plan whereby the 10 most common disease states and their pharmacotherapy is reviewed.
- Last Week of the Rotation: Students are expected to complete all normal rotation activities during the 48 hours preceding the exam as guided by the preceptor. The majority of preparation time shall be outside the normal clerkship schedule, however, review of the medical record, shall be done on site. Preceptors should remind students of the confidentiality of medical records and site-specific policies involving retrieval and review of medical records. No student notes should identify a patient by name or medical record number. The written case work-up may be used by the student as an aid in the verbal exam. A written case work-up is developed as a student aid only; it will not be graded in any fashion. Students may elect to complete the verbal exam without any notes or with extensive notes.
- Exam Day: The primary preceptor will administer the exam. If desired, students may use written case-specific notes. The exam will generally last no longer than 30 minutes. During the exam, the preceptor will assess the student's knowledge of the pathophysiology and pharmacotherapy of the disease, drug-related problems, and therapeutic decision-making (recommendations, monitoring, etc.). The Written/Verbal Examination Assessment tools will guide both the student and preceptor in choosing areas of emphasis for the verbal exam. During the exam, the student may refer only to their case-specific notes. References (print or on-line) shall not be accessed during the 30-minute exam.
- Grading: A numerical grade will be assigned for the examination based upon the criteria published in the course manual. Any make up or delays for the final examination are under the sole discretion of the primary preceptor. However, final examinations cannot be administered after the rotation dates except in cases of previously approved authorized absences.