In this article, Azhar Jiwa describes his hospital training so far and provides useful advice on how you can get through your training smoothly
Addenbrooke’s Hospital (Cambridge University Hospitals NHS Foundation Trust) is a 1,100-bed teaching hospital that is a tertiary referral centre based on a biomedical research campus. It is here that I started as one of 10 preregistration trainee pharmacists in July 2012. I chose the hospital sector because of the variety of clinical exposure and the structure that the training programme offered.
The typical day of a trainee here is usually split into two parts: clinical wards in the morning and departmental duties in the afternoon. We start our clinical time by visiting the wards with a senior pharmacist for about two hours, where we are assigned a small bay of patients to review and present to the pharmacist. New patients need medicines reconciliation completed and, where appropriate, drug histories are taken.
Existing patients need to be monitored and reviewed for any medication changes. Additionally, patients may need counselling about their medicines and relevant care plan issues need to be highlighted to other healthcare professionals. Each ward rotation lasts for two to four weeks and clinical areas covered include surgery, medicine (hepatology, renal, elderly care), medical admissions, paediatrics and neurology.
Additionally, each trainee also spends one week shadowing a pharmacist on either the transplant ward or the critical care unit. In a big teaching hospital, all of this can be daunting for those who have not spent much time on the wards before. Therefore, we undertake a structured ward-training programme that accredits our skills and expands our responsibilities during the year. Our work on the wards is supervised by pharmacists and we receive regular feedback. With each phase of our training, we become more independent, but we also shoulder more responsibilities, thus preparing us for life as a qualified pharmacist.
After we have finished on the wards, we have protected self-directed study time where we are able to reflect on and address any identified learning needs. Here we spend our time looking up local and national policies, revising clinical topics or writing pieces of evidence to demonstrate our ability to perform the different General Pharmaceutical Council performance standards. In a large teaching hospital, it can be difficult to spend much time with your tutor on the wards because we are often changing rotations to gain a wider scope of the different areas. Therefore, weekly meetings with our tutor and having a portfolio of evidence are critical elements in achieving and demonstrating competence.
Departmental duties usually occupy the second half of the day and, where possible, complement our ward rotation. For example, a rotation in oncology would be matched with time spent working on an oncology ward. Departmental rotations include stores, clinical trials, preparative services, quality assurance, medicine information and, of course, the dispensary. Here we are able to develop much of the skills and knowledge needed to demonstrate competencies of a pharmacist. Additionally, with each clinical rotation and department, we gain a better understanding of the patient journey, as well as the movement of medicines within the hospital.
For example, in oncology, I was able to see how the drugs were procured, how the medicines were prepared, the final products clinically checked and subsequently administered to a patient in the day clinic. At Addenbrooke’s we also have two-week rotations in community pharmacy, and also at a nearby mental health trust (Fulbourn Hospital). Being part of so many teams has its advantages, one of which is the opportunity to develop strong communication skills, both written and oral, which can be adapted and transferred to any team one works with once qualified.
Thus far, I have enjoyed my time specifically within medicines information. Here I spent four weeks under the supervision of the lead pharmacist. Half of this time was spent working through the UKMi training workbook and MiCal (a computer aided learning tool), and the other half answering enquiries.
Personally, I found that medicines information was always challenging as one has to provide advice for difficult enquiries from practically every area of medicine imaginable. In addition to the lead pharmacist’s humour, he always challenged us by showing different angles to the problem. For example, if the enquiry was about drug interactions, he discussed with us how the drugs work in order to encourage us to consider any pharmacodynamic interactions. This was useful because many of the drug interaction resources (the BNF, Stockley’s, Martindale, etc) only consider pharmacokinetic interactions. For me this demonstrated how understanding a problem, thinking about it, and presenting a solution or advice are far beyond just looking up information in a book or using an electronic resource.
Clinical trials is a distinct experience at Addenbrooke’s, with approximately 130 trials currently running. During the year, trainees have the opportunity to gain an understanding of different trial protocols and good clinical practice, to observe trial set up meetings and to dispense a wide range of clinical trials.
My time at Fulbourn (the mental health hospital) was a unique opportunity to work with a different patient group. The patients there often had a complex medical and pharmaceutical history, and the goals of treatment were often different from those in an acute trust.
Here, I attended a community-based clozapine clinic, a presentation of a case study and a multidisciplinary team meeting, where the patients are seen one to one in a room of collective healthcare professionals rather than the teams individually seeing each patient by their bedside. Although one cannot become a specialist in two weeks, this opportunity allowed me to focus on understanding how to manage patients on drugs like clozapine and lithium, and it clearly illustrated different approaches and focuses of patient care.
There are so many specialist areas. No trainee can see them all without sacrificing the quality of training by being there for such a short time that little could be gained. Fortunately, for us, our timetables have built in at the end of our year three weeks where we can request to visit an area that we thought we needed more time in or did not have a chance to see at all.
Additionally, in the spirit of embracing the diversity of services in and out of the hospital, we are also given one day with another professional. We arrange this ourselves; it can be with a specialist pharmacist, laboratory researcher, paramedic, physician, or any other professional involved, directly or indirectly, in a patient’s care. I believe initiatives like this are critical in understanding the system as a whole. They also keep a trainee’s interest and imagination flowing because pharmacy is always pushing new barriers. In fact, there are so many things to see and learn that I still have not decided what area I hope to spend this day in.
In addition to time spent in the hospital, the region also invests in four weeks of pre-registration trainee conferences where they conduct objective structured clinical examinations, cover legal, ethical and clinical topics, and co-ordinate mock examinations. Our learning from the conferences is underpinned by an e-learning site that we access in order to undertake any specified pre-conference activities. The regional co-ordinators are working to expand this e-learning site and have been seeking trainee input as to how we would like this to be developed. Back at base, on the weeks we do not have scheduled teaching sessions, the trainees also get a chance to teach and learn from each other through presenting care plans about patients we have seen on the wards.
Working with so many teams and always meeting new people is not easy for everyone to manage, especially if your preregistration post is in a new city. If I can be presumptuous enough to suggest a few things from my own experience I would say:
• Carry a notepad for writing down specific points you want to highlight to the pharmacist on the ward to personal notes and reflections on ways to improve your practice. It is a must.
• Be open and embracing of new experiences and opportunities.
• Contact the person you are going to be with for each new rotation at least a week before hand.
• Always enquire proactively about any suggested reading or local policies because this will help one to become familiar with patient care and the department itself.
• Try to write your evidences as promptly as possible.
• Be aware of your resources and available support.
• Remember it is a training year so you will not be good at everything. Do not be afraid to say you do not know, take your time learning and reflecting. So be ready to take feedback from all direction, both positive and negative, and develop a thicker skin. It is better that you learn now rather than to make a mistake when you are qualified.
• Lastly, strike a good work-life balance.
Thinking about taking the route to hospital practice?
seriously interested in pursuing a career in hospital pharmacy I would strongly suggest applying for a summer placement at a hospital and
specifically at the hospitals you are thinking of applying to. This will
give you an idea of what happens at those places and if it suits you. I
think one important thing to understand is that no one hospital is
perfect for everyone. For example, at Addenbrooke’s, being one of 10
preregistration trainees can be daunting for many and does require one
to be proactive about one’s learning. However, for others, this may be
more exciting and the price one must pay to be in a large place that
gives one the opportunity to see so many things.
But also note the unique points about that programme. Ask yourself what really sets this place apart from the rest and you will find each hospital is unique in its own way. Regardless of where you end up even in the best of places you will still only get out of the year what you put into it, so be prepared for a busy, challenging and hopefully enjoyable year.
Azhar Jiwa is a preregistration trainee at Addenbrooke's Hospital