The End of Winter Break

Even though I was working during winter break, I still managed to enjoy my time off. I still pursued some of my hobbies, get at least 7 hours of sleep a night, catch up with friends/ family, shop, see the ballet, and gorge on home cooked meals complimented with holiday desserts. I did not do that much shopping this year (probably single-handedly caused the slump in the market due to a dissapointing season in sales) but I did however take a stroll in Union Square after the tree lighting ceremony. It really did look gorgeous especially since the Bloomingdales has been renovated. We are returning to school on wednesday which means that I need to get my "back to school" tasks done. Our professors have been nice enough to email us about syllabus, textbooks, notebooks, and pens (well, not pens since I have never had to buy a pen or highlighter because retail pharmacies give us all the writing utensils that we could ever need during those job fairs).
Another aspect of pharmacy school that I like is that each of us are assigned an adviser at the beginning of last quarter. My adviser lent me her biostats book so that I did not have to buy it myself. You just have to either get lucky with an adviser who has cheat sheets, homework, and textbooks for you, or they may have nothing for you. Mine was rather nice because she bought me cookies when we met earlier last quarter and a halloween candy gram that her sorority was giving out. Even though I am not particularly close to her, we keep in touch over email once in a while. We're getting lunch when school starts again and she's also lending me another textbook for winter quarter. I plan to do something nice for her for her advice and all.
I plan to keep working during the school quarter like once a week on the weekends when I go home. I can make enough to pay off my rent every month (yeah!). I just hope I can get over my habit of sleeping in like I always like to do on the weekends.
Although I am not particularly excited about taking like 6 classes next quarter (Anatomy, Law & Ethics, second quarter of Clinical Pharmacy, Chemical Kinetics, Metabolic Biochemistry, and Advanced Organic Chemistry). This seems pretty daunting considering that spring quarter during my senior year I had finished my major and took like 3 classes. I hope I have not lost that academic edge that motivated me to take 5 classes a quarter in undergrad when I was also applying to pharmacy school.
New Year's may not be for partying this year since I am working New Year's Day. Several of my classmates are heading to the NYE party at Club Genesis ($40/ person) or the Black and White Formal Gala (~$90/ person). Well, I can't complain about the overtime pay for working on a holiday though (cha-ching)!
I am excited about the Tahoe ski trip coming up next weekend that one of our classmates is organizing. We will be going snowshoeing, skiing/snowboarding, and shopping in Reno.

Life as a Technician

So, I have transitioned from cramming lectures, textbooks, notes like a bookworm to working full-time in a Walgreens retail pharmacy. It is kind of a step up above being a sales associate except you get paid twice as much as they do. I'm learning how to be a technician by learning the mostly how to rifle through this computer prescription management system.

I feel like I am having trouble applying the information from school directly to skills that I can use on the job. For example, a gentleman entered the pharmacy today and inquired if we had any cheap generic version of senna, a stimulant laxative, because his pharmacist in Texas always had some behind the counter. Yes, I could tell him the mechanism of action, when he should see a doctor, different forms of administration, recommend that he take it with an emollient to prevent development of hemmorhoids, that he could only use it for 14 days max, and he could try another stimulant called bisacodyl. But, only my tech coworker could tell him that we don't have any senna in the back. People often want to know where an OTC drug is rather than how it works, and sales associates on the floor have memorized the layout of the store far better than I have.

Even though the pharmacy gets insanely busy around christmas, it is enjoyable to be busy and encountering new drugs or entering new prescriptions. Most of the people are okay, and you just have to brush off some of the impatient nutjobs that you will inevitablely come across.

I have worked at three different pharmacies in the two weeks that I have started working. My managers are all really nice. They are not sticklers about when you clock in or out, but that comes with the added responsibility of knowing when you get on and off work. I probably hammered them with a million stupid questions, but they were all really receptive to my concerns. For example, I was clueless when a patient asked for a generic 1.0 mL medium insulin syringes. I now know to look for the walgreens 1.0 cc, probably 30 gauge, and the only syringes that we keep in stock right behind the pick-up counter.

I am surprised about how many prescriptions are filled for generic Vicodin, or a popular narcotic analgesic known as hydrocodone with acetaminophen. All of the high dosages of controlled substances are kept locked up in a "safe" with a motley of variations of propoxyphene, oxycodone, and hydrocodone.

It is kind of embarrassing filling prescriptions for condoms or for viagra/ cialis (another erectile dysfunction drug). I can't believe they would shell out 30 bucks for like 2 viagra tablets. I guess it can be worth it...

Some drugs that may become the next blockbusters, if any of you are looking to buy stocks in pharmaceutical companies, are Lamictal and Risperidal. Lamictal is a newly FDA approved prescription anti-convulsant to prevent siezures in children and bipolar disorder. Risperidal is the only antipsychotic recently FDA approved to autism in kids.

Winter Vacation

So, you would think that 1st year pharmacy students would probably have an entire month separated from pharmacy right? Well, I personally have spent this break with a heightened sensitivity to anything remotely related to all the knowledge I stuffed into my head this past quarter.

We all still had general nervousness about recieving our first grades in pharm school. That translated to checking student portal every day to see whether our grades were posted and emailing each other the good or bad news. And it did not help that Schaffer, our PChem professor, did not post grades until 2 weeks into winter break. P2 students keep reminding us that grades do not really matter anymore. But since a lot of us have residencies on the back of our minds, we all strive to get at least a 3.5.

Another example is that I have a greater awareness to every single new prescription drug commercials that comes on. Whenever I hear about controlled release Ambien CR, see dancing nicorette gum pieces, or hear the selling point about the "only asthma medication that fights the inflammation and allergic reaction" (Advair diskus which has the generic name of Salmeterol/ Fluticasone). You know you are a nerd when you say in your head "I know why that is!" when you see the ad about why "only Pepcid Complete acts to fight heartburn immediately and throughout the night."

Also, starting interning in a retail pharmacy (Walgreens) really drills all those random facts from Clinical Pharmacy 111 into your head. The training site is actually different than the site where I would be working (all results of a centralized human resources department). My first week working was spent at the computer watching all the orientation videos and taking the online technician drill quizzes. This was an overview of HIPAA (Health Information Portability and Protection Act or something of that nature), DEA (Drug Enforcement Agency) required paperwork to fill out for dispensing and keeping inventory of scheduled drugs. What I didn't expect were quizzes of what looked like information taken straight out of our pharmaceutical calculations quizzes: all the abbreviations used for prescription signia, factor analysis, etc. And obviously there were tests about matching brand and generic equivalent drugs.

I finished orienting myself with using their website "Storenet" which contains all the information about stock options, which you can't really take advantage of until after a year of employment. There were also retirement plans and other benefits listed, but that only is applicable after you become a full-time pharmacists. It was kind of cool how they gave out free drugs during Hurricane Katrina. Another area that caught my attention was the specialty pharmacy programs, diabetes, HIV, and infectious disease immunizations. I had no idea that Walgreens even provides home care, specifically only infusions in the east bay. Their Medicare Part D assistance program provides plans customized for each senior's health situation. The aspect that was particularly of interest to me was the scholarship information. Walgreens provides a few grand, that increases with each year that you are enrolled in pharmacy school, if you work as a registered pharmacist for the number of years that you recieve scholarship money. It is tempting but also a large commitment. My classmates and I were all thinking about this option, but it seems too early to make any decisions at this point.

I was bored during the last few days because I finished all the computer-based orientation and there wasn't really anyone watching over us, so I decided to read some other information on Charles Walgreens. He was Swedish and his last name was originally "Wahlgren." I just didn't realize that this multi-million dollar CEO was also a pharmacist who believed very much in promoting his profession. It's amazing how he built the retail pharmacy as we now know it today. He took out loans to increase the number of stores in Chicago in the 2o's, when Walgreens was originally known for their soda fountains and famous "malted milks." Back then, only 4% of their profits came from pharmacy. Now the restaurant services have been torn down, and over 50% of Walgreen's profits come from pharmacy. Walgreens tore down the shelves that blocked the view customers have inside the pharmacy because he caught a pharmacist drinking in the back on the job with female cosmeticians on his lap. Ouch.

Most pharmacies back then displayed glass bottles of powders, liquids, dyes, sweeteers. They were compounded and mixed in the pharmacy while now most of the compounding is standardized in manufacturing. Apparently, Walgreens still upholds its compounding traditions by still offering flavoring or alternate dosage form preps, but is much less likely to be conducted.

Post-Finals

If you saw random pharmacy students loitering around inner sunset, that was probably because everyone got out of the last final of our first quarter this afternoon. Like a group of lost cattle, we collectively were in a state of shock from not having another textbook to study. During finals week, we were in a limbo state between going out to long, drawn-out large group lunches at a new Thai, Chinese, or Indian restaurant and frantically cramming as much information as humanly possible into our heads into the wee hours of the night. So in between fresh naan and Burmese sambusas, we had to work desperately to figure out how to apply hours and hours of lecture to a 3 hour test. I'm not sure if I can define this behavior as balancing work and play or a morbidly zombie-like bipolar way of existence.

I think during the first quarter I personally was trying to do everything I could in terms of attending classes, socializing with an entirely new group of people, maintaining my relationship with my parents, seeing the city, getting involved in leadership positions, absorbing the broader perspective of where the profession of pharmacy was going and where the system would allow me to start experiencing it (as in internships). It reminded me of the anxiety that I felt in my first quarter of college, except more intense because you realize this is actually your profession and your profession is you. A lot of my classmates from Southern California are homesick, a common symptom of your first quarter attending school so far away from your familiar surroundings. A common complaint is that they can't stand the chill of the city, miss their late night mexican joints, the freedom of having a car and finding parking, and the distance between them and their signifigant others/ families. But at the same time, the Thai, Korean, Chinese, and Sushi restaurants are pretty good quality for what you spend. There's always public transportation everywhere you go so you don't need to deal with paying for gas or taking care of your car. And well, it's cold, but you deal with it? lol.

What is nice about being a pharmacy student is having an entire month off as opposed to the medical students whom only have two weeks of winter vacation.

So what are the pharmacy students going to do with a month off from school?

A large number of people are heading to Anaheim during Dec. 3rd-7th for the American Society of Health-System Pharmacists Conference, an entire 4 days of conferences about policies pertinent of pharmacy students and pharmacists. The appeal is that UCSF reimburses them for the registration fees. Most of the people going are So-Cal natives and want to do a little partying, networking, and get involved in policymaking.

The weekend we get back, we are going on a class ski trip to Lake Tahoe. We are getting a cabin that will house about 25 people maximum. I'm certainly excited since this is the first time I will be skiing in like 10 years.

As for myself, I plan to stay in the city and start interning at a retail pharmacy. That does not mean that I will not have the opportunity to go out and enjoy some eclectic holiday shopping that Union Square is known for, watch some of those new movies of actual substance that come out around Christmas, and maybe make a trip to somewhere like Vegas for New Year's. I figure most things that I want to do, I can probably do in the Bay Area.

Complimentary and Alternative Medicines plus Tobacco Cessation

On Thursday, AphA-ASP sponsored an "OTC Herbal Medicines" Talk. This doctor who was trained in western medicine went to do a post-doc in china and then later taught Chinese medicine at UC Berkeley. She apparently received government funding to treat outbreaks of measles in the Chinese children and was active in promoting MMR vaccinations as well. She reviewed various herbs and medicines that could relieve common ills such as the cold, mild rashes, or pain. She stated that all of these remedies are available in Chinatowns throughout San Francisco and the Bay Area. Someone even asked how lay people can select effective Chinese medicines for their illnesses since these herbs are not FDA approved ( officially evaluated for their effectiveness, safety, or harmful interactions with pharmacologic agents). Her response was that people should consult knowledgeable Chinese herbalists who can give recommendations based on clinical trials that support the effectiveness and safety of the herbs.

But gathering from her talk, most of her recommendations come from her patients’ clinical outcomes, and not standardized clinical trials. But what was interesting was hearing the theories about imbalance of elements within a person that causes a disease to manifest. For example, too much heat or cold in the body could create an imbalance. Too much wind in a woman results in menstral cramps. It sounds like Feng Shui meets biology. The theories are too abstract for someone like me who has an empirical understanding rooted in the western medicine that is taught here at UCSF.

Even in our Clinical Pharmacy class, the herbal supplements section is mostly taught in a self-study format. We will only be covering 10 herbs this quarter, like Gingko Biloba and St. John’s Wort. And we do not even learn how to counsel someone how to use them, only know when to recommend to a patient to change dosages or not to use the herb concurrently with a drug due to an adverse drug reaction. St. John’s is well documented for inducing Cytochrome P450, which is an enzyme in the small intestines and the liver, that can decrease bioavailability of P450 substrates. It is daunting but interesting at the same time to realize the wealth of active ingredients that can be sequestered from natural sources. Optimistically, further research into uncovering new herbs can compliment or replace current accepted methods of treatment. It seems evident from her talk that we as future health professionals have a long way to go in terms of bridging these two systems of health care to call truly call it integrated medicine.

The pharmacies that are on the frontier of this movement is Pharmaca, a chain pharmacy that is growing at an exponential rate across the bay area which specializes in integrated medicine. I talked with their corporate recruiter a month ago about how they model their store after european pharmacies that provide herbs as well as pharmacological treatments. Their staff even includes acupuncturists, massage therapists, and other alternative medicine specialists.
The topic that we are delving into in clinical pharmacy class is Tobacco cessation. The program basically trains us about the importance of encouraging patients to quit, review of the physiological effect of nicotine and smoke on the body, how to counsel them about lifestyle changes that can improve rates of quitting, and pharmacologic treatments that can ease the withdrawal symptoms. I think this is the best series in the whole course since the instructors did a really thorough job on everything that we need to know about understanding how these treatments work, how to talk to a smoker, and the goals of how ending this behavior can decrease their chances of cardiovascular disease, stroke, asthma, COPD, and lung cancer.

They even did a shpeel on how the Tobacco industry has done everything they could to hook people on this drug for profit. For example, "Light" cigarrettes were marketed to be cleaner than regular cigarrettes. They were designed with ventilation holes to allow smoke to emit without entering the body, but they contain almost the same amount of nicotine and people inhale the same amount of smoke by covering the ventilation holes with their mouths when the take a puff. It is designed to be addictive since the nicotine reaches the brain to increase release of dopamine in the brainstem under 11 seconds, faster than most drug delivery systems developed today. Therefore this fast delivery of pleasure immediately after smoking a cigarrette reinforces the behavior of smoking.

Post 2nd Round of Midterms

This week was as busy as ever with another round of midterms and flurry of various club meetings. We took our last physical chemistry midterm, which was the most challenging out of the three that we have taken in terms of the material. Ever since we switched professors from Voigt to Schaffer, our lectures and homeworks have become increasingly complex. Part of the difficulty comes from Schaffer using calculus-based explanations of the material, for example understanding equilibrium between a pure liquid with its vapor as a discontinuity between two chemical potential curves, but mostly it is the result of shifting the focus of the class from understanding the concept of state functions to thermodynamics applicable to protein binding and pharmacodynamic studies. I enjoy this second half of the course much more because it is conceptually challenging while still keeping the problem solving understandable (basic calculus and algebra).

We also took our second biopharmaceutics midterm, which went ok. I could have done better since this class is really a simplified version of the pharmacology class that I took in undergrad at UCSD. Our curve was exceptionally high, with about 85% of the class getting an A. This is somewhat intimidating coming from undergrad classes where the curve was 50-60% which allowed you to make mistakes. But I suppose the expectations in biopharm and clinical pharmacy are a lot higher since the material is relatively easier and absolutely applicable to your future career. Every time I make a mistake I think about what a miscalculated dose could do to a patient. I wonder if this burden will ever go away (probably not).

As for extracurriculars….Here are a few out of many…

APhA is having its annual Patient Counseling Competition and a whopping 70 pharmacy students signed up to compete! This is about three times the number in previous years and can only be attributed to a growth of participation in my fellow classmates. I went to the info night and watched the video of last year’s national winner of the competition, also UCSF pharmacy student Eric Ip, counsel a patient in the national competition. He was so thorough when it came to knowing any side effects, customizing his responses to the patient’s needs, and reviewing proper dosage instructions. I still can’t believe he only had 5 minutes to prepare for the session. I realize that I have a lot to learn before I can reach his level.

Last week, we turned in our pledge cards for which fraternity we would pledge for. There are only two pharmacy fraternities at UCSF: Kappa Psi and Phi Delta Chi. From talking to the members, my impression is that Kappa Psi is more social (work hard play hard mentality) while PDC is like a low-key sorority. Pharmacy is already severely polarized (our class with about 100 females and 20 males), so it doesn’t really help the integration of the class when most of the males, non-asian ethnicities, and other minorities all pledged Kappa Psi. The break down this year was 75 pledged KY and only 20 pledged PDC (it was about 50:50 last year). They surprised us this week with breakfast and carnations in the morning before class. I never joined a frat in undergrad, so having such an intense frat presence in my school experience is very different for me. It is nice to have organizations that bring different class levels together.

We had a mandatory meeting for the California Society of Health Pharmacists information session about the conference in Anaheim Dec. 3^rd through 7^th. A large number of our class is interested, especially since the school will reimburse up to 184 dollars of the registration fees.

Also, there have been a series of talks given by some of the major experts in the developments in Medicare Part D. I am really happy that I came to UCSF so that I can hear some of these professors and 4^th year pharmacy students give these really informative talks about what a donut hole is, how late sign-ups for Part D can result in penalties, how benzodiazepines/barbiturates are not covered under the formularies, differences between this program and state run insurance plans, etc.

Summary of October

Let me first say that my experience here at UCSF Pharmacy School is just one voice and not representative of the diverse opinions about the curriculum and student life here. I have a lot of respect for the vast majority of my classmates because they are really genuinely caring, intelligent, and dedicated individuals. The first month is a flurry of orientations, social events, exploration of the city, and food food food!! Our biggest event was the White Coat Ceremony where we donned our new white coats and pledged our duty to the profession of pharmacy.

I attended this AIDS forum on October 13-14th as a one-unit elective class. It was pretty interesting to hear lectures about everything from the most recent research in AIDS treatment, epidemiology of the disease on an international scale, to real life anecdotes about what it was like to live with the disease. Since I did not have a strong grasp on the molecular biology of the disease, I learned that a patient's CD4 Helper T-cell count, the number of infected cells that spread the virus, can be used to measure the progression of the disease. New research suggests that CD8+ Killer T-cells may serve as a treatment solution to suppress CD4's. I learned a little about protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and these new integrase inhibitors that are coming out. Apparently HiV clinics have this 20 minute blood test for HIV, but it's ridiculous cuz there's a 99% chance that it tests positive when you don't have it.

In terms of classes...
I was stressing this whole weekend about this clinical pharmacy midterm that's coming up on tuesday. So far, we covered gas, hemmorhoids, diarrhea, and constipation. The major source of anxiety that I sense among the class is condensing all the important information we need to work in a pharmacy into a "self-study" format. In conference, we analyze two cases per class. But we barely have enough time to cover the first case before we can thoroughly discuss the second one. I feel like I'm being immersed in this task of memorizing all the condraindications of drugs, side effects, mechanisms of action, and brand v. generic names, and therapeutic classes without understanding how they really work. I think taking a crash course in physiology would have given us the foundation to understand and retain why drugs work a certain way. For example, if our professor would have explained in lecture that Ca2+ influx into Ca2+ channels into heart muscle cells leads to heart contraction, then many more people would understand why Ca2+ channel blockers like Amlodipine can lower cardiac output and blood pressure.

Biostats is just like undergrad statistics that I took in UCSD. The tests are more difficult though, but our professor is an excellent lecturer. The compilation CD that a Pharmacy Frat (Phi Delta Chi) made is absolutely essential for preparing for tests.

I have taken physical chemistry in undergrad, but this class is still challenging nonetheless because our professor expects us to know and have equivalent problem solving skills as chemical engineers. This class is not particularly necessary to pursue a career in pharmacy, but understanding thermodynamics, colligative properties, phase changes, equilibrium of chemicals may be an advantage in a compounding pharmacy or pharmacological research.

I think I was stressed out because I had this interview for a pharmacy internship position at Walgreens the day before my Physical Chemistry midterm. It was random because I had to take the 34 to Laguna Honda Hospital and switch to metro L to meet my interviewer at Walgreens. I passed through the more expensive houses west of downtown until I reached 40th and Tarval. Not only was my interviewer half an hour late, but I was worried cuz I planned this study session at later that night. I got so bored that I started passing down the aisles and studying the drug facts on the OTC drugs, since I needed to know them for my midterm.

The interview went pretty well. Since I volunteered at a homeless clinic before, he asked me my opinion of the growing number of people without adequate health insurance in california. Since I was taking this health insurance elective CP198, I pulled out a common theme that the professor kept reiterating, which was that pharmacists have this essential role in educating the patient about redeeming benefits of government-sponsored health insurance like medical or medicare Part-D. The pharmacist can play a key role in deciphering the world of formularies, co-payments, premiums, and quarterly changes to insurance policies that lead to a lot of confusion for people.

It was basically like going through another pharmacy school interview, but somewhat less formal. He said that I could start as a script writer even though I did not have my intern license yet, so I told him that I could start training in december.