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Rural Hospitals as Pharmacy Student Training Sites

by DeeAnn Wedemeyer-Oleson
Large medical centers in urban areas are frequently used as experiential training sites for pharmacy students across the country. However, don’t rule out rural hospitals as great places for pharmacy students to learn! Guthrie County Hospital has been a clinical rotation site for Drake University College of Pharmacy students since shortly after I arrived in July of 2000. As the pharmacy department has grown over the past seven years, so has the role of our pharmacy students. Brenda Halling, R.Ph., Clinical Staff Pharmacist, and I consider our students to be integral members of the pharmacy team. Under our supervision and guidance, our students are expected to assume clinical responsibilities, which are clearly outlined for them on the first day of their rotation. Drake University Pharm.D. candidates have been instrumental in the success of our clinical pharmacy services. 
I have mentioned in previous columns some of the ways students provide support to our clinical pharmacy services at Guthrie County Hospital. Here is a more complete list that might give you some ideas for utilizing students in your own rural practice:
·          Obtaining admission medication histories and performing medication reconciliation
·          Screening patients for adult vaccination protocols, such as pneumonia and influenza
·          Thoroughly evaluating drug therapy on assigned inpatients and identifying drug therapy problems to bring to the attention of the pharmacists and prescribers
·          Rounding with medical staff to make recommendations about assigned inpatients and provide drug information
·          Performing calculations and making recommendations for the pharmacy’s pharmacokinetics service
·          Attendance at care planning meetings, including providing verbal updates about assigned patients to the interdisciplinary team members regarding medication-related issues they are working on
·          Providing medication education to inpatients at discharge, including addressing medication adherence concerns that the patient and/or their caregivers might encounter upon returning home
·          Providing medication education to outpatients such as cardiac and pulmonary rehabilitation patients, as well as assisting with teaching diabetes education group classes
·          Assisting pharmacists and physicians in the clinic setting including helping with the anticoagulation service, performing medication reviews, teaching patients about new medications, and providing diabetes education services such as glucometer and insulin injection training
·          Researching drug information requests
·          Presenting in- service education to medical, pharmacy and nursing staff
·          Researching and preparing formulary recommendations and drug therapy protocols for the P&T Committee
As you can see from the above, we keep our students very busy! Direct involvement in these clinical services provides our Drake University pharmacy students with varied and ample learning experiences. These learning activities also provide us, as preceptors, with multiple opportunities to assess their performance and give feedback. We believe that these activities contribute to the development of the following core clinical skills in our students:
·          Obtaining and assessing comprehensive medication information
·          Identifying drug- related problems and communicating recommendations to prescribers
·          Medication reconciliation and the importance of continuity of care
·          Working as part of a multidisciplinary team
·          Communication and education with patients and/or their caregivers
·          Assisting patients and caregivers with implementing strategies for medication regimen adherence
·          Documentation of care provided
·          Educating fellow healthcare professionals
·          Instilling a sense of responsibility to patients, fellow pharmacists and other healthcare professionals
I believe that rural hospitals are wonderful settings for pharmacy student training for many reasons. First, rural hospitals are much less intimidating than large medical centers. Many students come to us having had little exposure to the hospital environment and have told us that they were grateful they had a rotation in a small hospital before moving on to another rotation in a large hospital. The small hospital allowed them to adjust to the hospital setting without feeling overwhelmed and they then felt more confident going to a large, urban hospital.
The second reason I feel that small hospitals serve as great rotation sites is that, because of a relatively low patient census compared to large hospitals, students are able to spend ample time evaluating medication regimens. While as pharmacists we know that we do not often have time to assess drug therapy for all of our patients as thoroughly as we would like, it is important that students have adequate time to do perform comprehensive evaluations. It is during clinical rotations when students will hone their drug therapy evaluation skills they have learned in the classroom. Brenda and I feel that this is the time for them to develop the process of drug therapy evaluations; the speed at which they are able to perform these mental processes will increase with practice. We provide students with a template for their drug therapy assessments on the first day of the rotation that includes all of the information we expect to see them gather and the questions we want them to think about when they are looking for drug therapy problems, considering interventions and developing their monitoring plans. When we review patient work ups with the students, it is how comprehensive they are that it is important to us and we believe that a small patient census allows them the time they need to do this. 
The third reason rural hospitals can be ideal rotation sites is that students are frequently able to see true continuity of care. Our students typically begin getting to know their patients when they perform their admission medication history. The students are then expected to follow their patient through their hospital stay including discussing recommendations with the patient’s physician and giving an update to the interdisciplinary team at care planning meetings. The students perform medication reconciliation in cooperation with the physician and provide medication education to their patient and/or their caregivers at the time of discharge. The students are responsible for communicating the discharge medication regimen with everyone involved in the patient’s care including the physician they will be following up with and any home health care providers the patient might receive care from after discharge. The students often see their patients after they are discharged, either during a follow up visit in one of the family medicine clinics or during nursing home rounds.   
The last, but not least, reason I feel so strongly that rural hospitals should be utilized as clinical rotation sites is so that pharmacy students in their final year have the opportunity to experience rural hospital pharmacy practice. Many times in this column I have talked about the advantages of small hospital pharmacy. I love sharing my passion for rural hospital practice with our students! We are all too well aware of the pharmacist shortage and this is especially true in rural settings where recruitment is particularly difficult. Practicing in rural settings has its challenges, but it is up to those of us who know just how fortunate we are to be rural pharmacists to encourage pharmacy students to consider it as an option.

For those rural hospital pharmacists who do not currently serve as pharmacy student preceptors, I hope this column has caused you to contemplate contacting the colleges of pharmacy closest to you to discuss the possibility of becoming an experiential site. For those of you who are already preceptors, THANK YOU for giving your time and knowledge to prepare future pharmacy practitioners!