Pursuing a PGY2 infectious diseases pharmacy residency on your mind? Here is insight on moving forward with your plan from someone who is there now!
Authored By: Eliza Dollard, Pharm.D.
Infectious Diseases (ID) was my first rotation as a P4 pharmacy student and from there I was hooked. I love the combination of microbiology, antimicrobial resistance, stewardship, pharmacokinetics and pharmacodynamics. The field of ID Pharmacy is rapidly growing in response to the global implications of antibiotic overuse and this dynamic environment creates countless opportunities for professional growth. I feel very fortunate to be beginning a career in such an important and exciting specialty.
Although I knew from the beginning that I wanted to specialize in ID, I cannot say that I have always excelled in this area. The ID module was my lowest grade in pharmacy school and I struggled with memorizing what seemed like endless bug-drug combinations, dosing, antibiotic limitations and indications. It was not until I started clinical rotations that all of the information started coming together for me. I worked harder at memorizing the information I had struggled with in the past and I slowly gained knowledge and confidence.
Contrary to my previous belief, I realized that choosing a specialty has very little to do with your initial talent. It is more important to choose the specialty that interests you the most; one you will not mind spending a lifetime reading about, memorizing information, and teaching.
When it came time to apply to a pharmacy residency, I narrowed my search to only include programs that had an ID PGY-2. I wanted to have the opportunity to learn in an environment with a well-organized and well-established ID/Antimicrobial Stewardship Program (ASP) which had a history of training residents and the potential opportunity to early commit to the PGY2 ID program. I was fortunate enough to match at a large tertiary care teaching hospital with a stewardship program that had been in place for more than 8 years, and I was ecstatic.
I communicated my goals with the ID PGY-2 director during my second week of my PGY-1 residency, and was eventually able to early commit to the ID PGY-2 position during my PGY-1 year, before the American Society of Health-System Pharmacists’ Midyear Clinical Meeting in December. Now as I am two months from completing my PGY-2, I can honestly say that the last year has been the most fulfilling year of my life. I am constantly challenging myself and learning new information, and I am grateful to be working within this specialty of which I am so passionate for.
Since I completed my PGY-1 and PGY-2 years in the same institution, there were many things I was expecting as I transitioned into my second year. However, there were a few aspects that caught me by surprise. The following points are those where my expectation clashed most with the reality that I have experienced.
1. I expected all ID attendings to be involved or interested in antimicrobial stewardship.
Almost all job descriptions for ID pharmacists involve some sort of stewardship role. When I started rounding with the ID consult team full-time I realized that unlike pharmacists, ID physicians are not automatically involved with stewardship activities. In fact, some of them have very little interest in stewardship in general. Commonly, there is only one attending in charge of working with the ID pharmacist to direct the ASP. The non-ASP ID attending physicians who work within the ID group have other duties, which are typically geared towards clinical work, research, administrative functions or other tasks.
2. I expected all physicians to be angered by antibiotic restrictions.
When I started regularly speaking with physicians requesting antibiotic approvals, I realized that many of them understand the importance the restrictions. At the institution where I completed my training, restrictions on ordering antibiotics are put into place for a variety of reasons, such as for their ability to induce drug-resistance, indication limitations, safer available alternatives, or high cost. I usually explain this information to physicians when they call, enforcing the fact that these restrictions are put in place to protect our patients and our institution.
On a daily basis, I have more positive conversations than negative ones. This may be attributable to the fact that I work in an institution that has had an ASP for many years with strong ID physician support. However, it gives me hope for new programs that may be struggling with this aspect, because over time the attitudes and culture of the institution may change.
3. I expected there would always be a straightforward answer.
In pharmacy school, you learn de-escalation with straightforward patient cases. “This patient is growing MSSA from a blood culture and is being treated with vancomycin, what do you do?” You write down the textbook-approved answer (usually oxacillin or cefazolin), and get an A on the assignment.
In practice textbook cases seem like the minority, especially working at a large institution with many immunosuppressed patients. Sometimes, there is no right answer. You may have evidence of infection but no positive cultures. Other times you may have a clear infection, with four different appropriate ways to treat it. In some of the most difficult cases, you may be trying to manage an infection that is resistant to every antibiotic you have available. Often guidelines don’t provide clear direction for what to do next. In recent years, drug shortages have added yet another level of complexity to managing infections. All things combined, it makes for a challenge to come up with a good treatment plan.
In understanding how to best work with my teams, I have learned to listen more and talk less. Although I may have choose to treat an infection differently, this does not always mean that the other practitioner is necessarily wrong. I have also learned that in some cases, de-escalation is not always the right move for the patient. It is important to evaluate each case in the context of the patient-specific variables, and understand that plans may change.
4. I expected the position of “ID Clinical Pharmacy Specialist” to have a similar description among all healthcare facilities.
When I was in pharmacy school I thought that an ID pharmacist would always round with the ID team, make recommendations, complete administrative projects, take rotational students, and give lectures. When I was completing my PGY-2 year and started applying to jobs, I realized that there are many different roads to take even after you choose to specialize.
Some roles are purely stewardship, academic or clinical, while many are a combination of all three. Variation amongst positions includes rounding responsibilities, venue (large tertiary teaching hospital vs small community hospitals), administrative responsibilities, resident and student precepting responsibilities, patient populations, etc.
These variables may create confusion when applying to jobs, but also create an opportunity for a more individualized approach to your career goals. I realized that it is important to fully understand the specific responsibilities when applying to positions in order to find a position that is a good fit for your interests and abilities. The most successful strategy is to communicate with potential employers, ask questions and be able to explain what your professional goals are.
5. I expected to feel ready to graduate.
Although I have learned a great deal this year, I believe the hardest transition of my life will be the transition from resident to independent pharmacist. I will be removed from the protective wings of my residency program director, and will be functioning as an independent practitioner for the first time.
When I get nervous, I just remind myself that I have been preparing for this transition for almost a decade. I have learned how to find information when I do not know the answer. I have gained experience through multitudes of projects, years of rounding, and hours of reading. I have all the tools necessary to be successful.
In the words of Albert Schweitzer, “Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful”.
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