Steph’s Note: Spoiler alert. I’m going to give all y’all a sneak peek - into the brains of your preceptors! (Sorry, I can’t get you the clinical stuff from their brains, that’s on you. But I am going to give you a glimpse into their teacher brains.) The preceptors of the world will either curse me for giving y’all too much of a roadmap into our expectations and thoughts, or (more likely) they’ll be thankful tl;dr is being proactive!

A little background here: I want to share these tips with you to help bridge the gap between learner and preceptor! If I can save you AND your preceptor the awkwardness of a critical midpoint evaluation and/or set you up for more success from day ONE of rotation because you know more of what your preceptor is expecting, by golly, why not?!?

Yes, I said, “By golly.” What can I say, I’m an old soul.

So take the red pill and step through the wardrobe. We’re going to take a quick trip through the top 5 things preceptors really don’t want to have to tell you (but we will because we feel invested in our learners’ development).

#1: Know your patients’ medications

It’s your first week of rotation. After you shadow during rounds, your preceptor assigns you a patient to start following with the intent of getting familiar with the EMR and the process of patient workup. You have some time to yourself to start digging around, and then you’re planning to go over later what you’ve learned about your person so far.

It’s overwhelming! Where to start? How much info does she want in your handoff draft/SOAP note? What order does it need to go in? What if she thinks your style is bumpkiss?

Yes, BUMPKISS?!?!?

Don’t worry. Of course, all of that will eventually matter. But you know what matters the most?

Hint: you’re a pharmacy student.

Look up the drugs!

As a preceptor, I am fully aware that we’re going to have to massage the note-writing skills and the order and depth of your patient presentation. I know you’re brand new to my rotation, and my style may be very different than the preceptor you just finished working with. I fully expect to work through the formulation of a problem list and associating objective information with an assessment and plan.

But what I’m really hoping is that, if nothing else, I can ask some questions about this or that medication and my learners will be able to tell me the basics:

mechanism of action,
usual dosing and any required adjustments (e.g., for renal dysfunction),
things to be monitoring for (i.e., common and/or severe adverse reactions), and
major drug interactions.

If you have these pieces at baseline, we can delve far more into your learning than if I have to wait for you to look up what class apixaban is. Perhaps we can look into the evidence behind apixaban’s use in valvular atrial fibrillation instead of spending our precious time together looking at the (hateful) clotting cascade.

Plus, to be honest, these details are what set pharmacists apart from the rest of the care team. Throughout school, we spend so much time learning guidelines, which is of course super important. But, spoiler alert, physicians and other providers learn those guidelines too. So we gotta find another niche if we’re going to be useful, and as pharmacists, that niche is knowing the DRUGS.

Now, I’m not saying you have to be an encyclopedia of drug information. That’s why we have drug references, and we all look up information constantly. In fact, it’s actually a skill to be able to say, “I don’t know, but I can find out.” (It can be a bit foreign to us type A pharmacists, but it’s important to know when you don’t know.)

That being said, you gotta at least have some basics on the tip of your tongue.

And btw, this baseline medication knowledge applies to all learners, no matter your intended future practice area. Admin, retail, institutional, home infusion, industry. You will all have PharmDs after your names (if you don’t already as a resident), so we should have some common knowledge.

#2: Investigate what (read: everything) you don’t know

If I had a quarter for every moment at work that I wished I just had more time to dig into an interesting patient case, I’d be off buying my horse ranch somewhere out west and galloping off into the sunset…

Oh sorry. Focus.

Basically, what I’m trying to say is that there is so SO much to learn and never enough time for all of it!

This kid kept asking why and just realized how much he doesn’t know. Don’t worry though. Like you, he can learn! (Image)

So as a preceptor, I essentially need my learners to turn into 5 year olds. Ask why. And what.

A LOT.

And before all the preceptors of the world send me hate mail, I don’t mean you have to ask your preceptor why every 2 minutes. (Give them at least 5 minutes in between why’s… KIDDING!).

When I say ask why, I mean when you’re working up your patients every day, ask yourself why…

Why did the team order that lab you’ve never seen before, and what is its significance?
Why could the patient’s lactate be so elevated? What’s that BNP flagging as abnormal?
Why did that serum creatinine just double? Was it the bumetanide we gave yesterday or the prolonged vomiting?
Why did they change from cefepime to meropenem?
Why did they choose 15 mg/kg/day of Bactrim?
Why is that enoxaparin twice daily?
What is nephrotic syndrome?
What is Behcet’s (and will google help me spell that if I start typing it in the search bar)?
What is aortitis?
What is the evidence behind using steroids in dermatomyositis? What is dermatomyostitis??

You get the idea.

Even if you feel like you’ve researched all the drug information that you can about your patients, I’m willing to bet every single one of those quarters I just collected that there’s more. And there’s certainly disease state information, lab data, or primary literature that is new or that you’re unsure how to interpret with regards to medications.

The more you understand the objective data you’re collecting from the EMR, the more you’ll be able to follow discussions during rounds, which will allow you to make more appropriate recommendations about pharmacotherapy. Even though we, as pharmacists, are not diagnosticians, we should be able to follow along to some degree with the providers’ decision trees.

Long story short, as a preceptor, I don’t really like hearing, “There’s not much going on with my patient right now, so I’m going to go work on X.” Because 9 times out of 10, there’s absolutely something more to learn.

Part of being a pharmacist is recognizing what you don’t know - and then having the drive to independently research. After doing so, come back with questions or thoughts and we can discuss together. Heck, you’ll more than likely teach us something!

But seriously, you will never ever again have so much dedicated time to learn. Before you know it, you’ll be responsible for a full service of patients or maybe the inventory and budget for your pharmacy. You’ll be tasked with meeting quotas and training new people.

And guess what, you’ll wish (just like all of us) that you had MORE TIME to figure out what’s going on with patients. So use your rotations wisely now and learn all you can.

#3: Be a professional

I don’t mean to sound like Grandma yelling at “those darn kids to get off my lawn,” but honestly, I need my learners to have standards. And some boundaries.

Let’s start with appearance. I know the times they are a changin’, and I realize people use their look as a personal statement (and sometimes a canvas). But perception actually does matter. And even if your younger colleagues happen to be more lenient about seeing your tattoos peeking out from your shirt sleeves or your nose ring, a lot of our elderly patients just plain aren’t used to that.

And to some degree, our job as pharmacists is about making a connection and gaining trust so that we can play an integral role in our patients’ care. Image plays a role in that, whether or not you believe it should.

So cover it up, tame your hair, and tone down the piercings. This isn’t Grey’s Anatomy.

Next item is communication.

Written communication should be clean and clear. This not only goes for that first email reaching out to your preceptor but all subsequent emails AND any project work you do. The initial case presentation draft you submit for your preceptor’s review should be free of typos. The journal club handout shouldn’t have misspelled drug names.

There are some things your preceptors just don’t knead to know (harrrrr). But then there are things we NEED to know. (Image)

(On that note, GASP! We’re the drug experts - we should always spell medications correctly! I once had a professor in school who said misspelling a drug name was the cardinal sin of pharmacy. Maybe a mite harsh…but not missing by much.)

Please take the time to scrutinize your written work. As a preceptor, we want to be able to make the most of our review time by focusing on your content. But y’all know we’re type A in pharmacy. So we are literally incapable of ignoring typos. And then we get distracted from the meat of the project. So basically, help us help you.

As far as verbal communication, it’s good practice to start your rotation with “Dr. Soandso”, and then when we tell you to call us Stephanie, that’s your cue that it’s ok. If we ask you how your weekend was (because we’re human too and like to get to know the people we’re with for so many hours), tell us about your hike, your dog, your family, or your trip out of town - not the raging night out at the bar for a bachelorette. There are some lines that shouldn’t be crossed.

Please don’t refer to your overdose patient as “crazy”. Watch how loud you are while presenting patients on the unit. Choose words and volume wisely for the sake of discretion and empathy. Your patients are someone’s family. Not to mention…HIPAA. Soft skills matter.

When we agree on deadlines for submissions of project drafts, please meet them. Or if something comes up (e.g., you get called in to work the weekend you thought you’d have off), please communicate that with us so we can revise the plan together.

This is so important. Plans change, responsibilities shift, and we understand that. Try to tell us ahead of time if you can! As professionals, there are certainly times we have to go to our groups and discuss changes to deadlines.

Ah De Niro and Stiller. The original circle of trust. (Image)

Because if you don’t keep us in the circle of trust, one of two things happens:

We’re left in a time crunch without enough leeway to fully review your work given everything else we have going on.
OR
The draft you submit just plain isn’t worth reviewing yet because you haven’t had a full chance to flesh it out.

And the third unfortunately inevitable thing that happens is that we’re looking at this crappy draft thinking, wow, we’ve got a LONG way to go. And, unless you tell us, we don’t know it’s because you just worked 21 days straight or that you had to travel home for your grandma’s funeral.

Again, communicate to help us help you.

Next is technology. These days, we are all connected at all times. And we’re busy people with piling responsibilities, and that goes for students too! You’re trying to stay involved and engaged with your groups, research projects, and academic activities to stay competitive in the job and residency market. Totally get that.

But that doesn’t necessarily mean we have to be connected at every single moment. For example, as a preceptor, I make an effort not to check my personal phone or my email when we’re in the middle of walking through patients or doing a topic discussion. (Unfortunately, my pager is mandatory, it’s part of patient care. Urgent issues arise.)

But I ask the same of my learners. Please don’t check your texts or emails while we’re in the middle of a thick patient presentation. (And yes, I know Apple watches get text messages.)

That being said, if there’s something particularly important that you absolutely need to check messages for, please do! Again, we are all human, and life doesn’t stop because you’re on rotation. Your dog is at the vet’s, you’re closing on your house, your mom’s having surgery, you have a phone interview, etc. Life happens. Been there, trust me.

All I ask is that you use good judgment. At the beginning of the day, give me a discreet, “I have an important personal matter that I’m waiting on a phone call/message about today, so if I check my phone, it’s for that.” That’s way better than me feeling like I’m talking to a wall about VTE prophylaxis while you’re semi-surreptitiously glancing at your phone or you feeling like you have to sneak peeks.

#4: Respect your preceptor’s time

If you haven’t noticed already, pharmacists are busy people. (I know, thank you, Captain Obvious.)

But really, we’re usually responsible for multiple services or hundreds of scripts, committee work, documentation everywhere, and covering for each other. And your learning. And we want to do well with all of these!

So if we arrange a meeting at 1 pm, do try to make it 1 pm. Not 1:20. Because likely in those 20 minutes we’re waiting, we’re probably getting paged about counseling this discharging patient or verifying some order in the queue. And then when you do arrive, we’re going to be stressed about time and not giving you our best teaching effort.

If we do patient presentations or topic discussions, please come prepared. Be ready to be fully engaged and attentive. If that takes a dose of caffeine, bring your cup (and maybe one for me… KIDDING!! Seriously, please do not buy me coffee or you will likely regret the chatter that ensues for like 2 hours). Have at least those basics we talked about in #1 researched so that we can get to the meat of your learning during the precious time we carve out, and if you have more than the basics, fantastic!

This also rolls into the presenting your best work for your preceptor’s review so that we can spend our time making meaningful suggestions and revisions for the next iteration. (Not correcting every apixiban to apixaban. Because you know we will.)

Unlike these two, we’re not trying to manage mischief as your preceptors. (Image)

Full disclaimer: I know preceptors also sometimes run late for meetings with you. I solemnly swear that I am NOT up to no good! We truly are trying to respect your time as well. You have many responsibilities, and we know that too.

So really, this section is about respecting each other because that’s a two way street.

#5: If you’re not sure, ask

More than likely, we won’t have discussed your patients in full detail prior to starting rounds at 8am - it’s not humanly possible. Also, unless you’re Super Student, there are patients on the service or floor that you’re not specifically covering.

We recognize this partial coverage can put y’all in a bit of an awkward position. We are all trained to be the drug expert. To be helpful and a resource for the team. It’s basically ingrained in our DNA by the time we’re finishing school.

So when the medical team asks you a question about one of the patients you’re not following or even something about one of your patients that we haven’t yet discussed, you may feel compelled to give an answer NOW. Trust me, I get it.

But please don’t.

Even if you’re spot on clinically and you’ve looked up the drug information and have a safe, efficacious, clinically sound answer (which is fantastic, btw, don’t stop researching the evidence!), there’s the problem of logistics. Sometimes institutional rules don’t go the way you think.

Maybe we don’t stock that nice, convenient combo inhaler you read about in the newest NEJM study. Maybe our policy allows for q4h vital checks, and it’s not fair or reasonable to the floor nurses to recommend those q15min assessments for this high risk drug the next 8 hours. Perhaps it seems harmless to say yes to allow the patient to use their home multivitamin supplement, but hospital policy may disagree due to the liability involved.

And just because institution/company A did it this way on your last rotation doesn’t mean institution/company B here does it the same. Even if you’re at the same place, sometimes the emergency department does things differently than acute care or ICU. (For better or for worse, we haven’t standardized quite that much yet.)

You might think big ticket items might be similar across all places, but they’re not. For example, I can tell you even something as seemingly simple as standard vancomycin infusion times has varied across the institutions I’ve worked at in the last 9 years.

Which may be crazy, but it’s the truth.

So before you recommend a new drug or promise the team that pharmacy can do something, please ask your preceptor. There is absolutely nothing wrong with saying to the team, “I think X would be a good idea, but just let me double check with my preceptor first.” That way, you can still demonstrate your clinical utility to the team (we preceptors don’t want to handcuff your growth and integration with them, quite the opposite!), but you’re also not making promises that may not be doable.

Part of being on rotation is learning to recognize when you don’t know something. And you may get surprised along the way. Maybe that drug the nurse asked you about crushing is actually an ER formulation.

Honestly, I hope you do get surprised - because those are the learning points that stick with you forever! As preceptors, we just want you to have those ah-ha! moments while working with a safety net. So for the sake of avoiding having to double back and reverse recommendations (or worse, realizing that you may have caused patient harm), please use us to bounce around your recommendations before making them.

Hopefully, as you and your preceptor work together, you will learn each other’s comfort zones, and you will determine when it is okay to make recommendations independently. Especially as a resident, it will be important for you to leave the nest and fly solo.

So please don’t think this section is about hindering your growth or reining you in! It’s really about ensuring patient safety and coloring within the institutional policy lines.

BONUS! #6: Your preceptor cares about your success

By now, I hope that y’all realize the only reason I’m writing this post is because I care. We all care. We wouldn’t be preceptors if we didn’t!

It takes a lot of time, energy, and planning to incorporate teaching into our crazy days, but we do it because we want to see you become that knowledgeable, integrated care giver. We had people who kept us on the right path when we were in your shoes, and we know just how much that guidance made a difference in our own stories.

We want to do the same for you. Which is why we will have the difficult midpoint discussion with you if we don’t feel like you’re on track. We don’t want to, it’s not easy for us either. We don’t enjoy it, you know. But we will do it.

But hopefully this post gives you a heads up going into rotations so that you can feel like you’re on the right footing from the start. Keep up the good work, stay engaged in your learning while you have the time, and rock out rotations!

Ok, bear with me. This one’s loose on relevance, but it’s just so darn cute. Your preceptor wants to guide you through your rotation like Simon guides Daisy down the stairs! And then you’ll be ready to do the stairs solo all the time!

(I know, I told you it was bad. But watch, and all will be better.)

Top 5 Things Your Preceptor Doesn't Want to Have to Tell You (But Will)