Taming the Beasts of APPE Rotations

Author: Justin Shiau, PharmD
Editor: Brentsen Wolf, PharmD

Transitioning into the last year of pharmacy school is one of the most difficult challenges for a pharmacy student (and arguably, THE most difficult). After spending a good couple of years building upon your pharmacy foundational knowledge through didactics, you suddenly find yourself in the drastically different environment of APPE (Advanced Pharmacy Practice Experience) rotations. Unlike all the years of being stuck inside the classroom and practicing on “patients”, APPE rotations are the start of real-life pharmacy practice. It can be, and IS, overwhelming (especially if you were like me and felt that you didn’t remember a ton from your therapeutics lectures). With that being said, now that I’m nearing the finish line of graduation, I’m here to provide a few pointers and give you some food for thought as you embark on this next leg of your journey. Let’s get started!

1. It is okay to NOT know everything: This is probably one of the most important things to keep in mind as a fourth-year pharmacy student. Most of us within pharmacy (myself included) have that “Type A” personality, so when it comes to preparation in general, we almost always try our best to predict any questions that will be asked of us. Students will often go into their rotations with the mindset of needing to know everything. After all, you’re in your last year of pharmacy school so why shouldn’t you? Realistically, it is nearly impossible to have all the answers to everything. There are going to be moments where an attending physician or your preceptor asks a question that you won’t know how to answer. Understand that while this is your last year, you are still a student, and that means one of your main objectives is to learn and prepare yourself for becoming a licensed pharmacist. One helpful tip for these situations which I’ve learned from a mentor is to answer the question by stating what you DO know and go from there. Even though you may not know the exact answer to the question, preceptors will still appreciate your thought process. Another tip for those instances when you don’t know something, it’s perfectly fine to say, “I’m not sure, but let me look into it and get back to you!” This is also a great segue into the next tip.

2. The importance of accountability and follow-up: It's important to make sure that when you say you'll follow-up with your preceptor or a physician, you actually DO follow-up with them. It's hard to believe, but there are quite a few instances where students will choose not to, which results in an unprofessional image and makes it look as if they cannot be depended on. Make sure that your actions reflect your words and that you follow-up in a timely manner. Use this as an opportunity to not only show that you are reliable but also to understand which topics you might need to refresh yourself on as you prepare for the NAPLEX.

3. General rotation essentials and helpful resources: You may already have a list of items that you plan to bring with you on rotations, but here are a few key things that definitely helped me as I was going through all of my rotations!

First, a backpack. I know it seems so simple to list this as a “key item”, but it truly is an essential item that you will use every day throughout your last year to help transport everything to and from rotations. Second, your laptop (with the charger). Usually, rotation sites will have computers for students to use but it is also highly dependent on the type of rotation. Having your laptop with you can be extremely useful especially if you’re going on inpatient rounds and need to quickly reference something for a recommendation. Third, a notebook and writing utensil. Again, this may seem obvious, but for me having a notebook on hand and something to write with came in handy for taking some quick notes or writing down reminders on the tasks that I had to do for each rotation.

Some helpful resources that I constantly found myself referring to include drug information resources (e.g., Lexicomp or Micromedex), treatment guidelines (you probably already know this, but Google is your best friend when it comes to searching for the latest guidelines), and a few phone apps. If you don’t already have the “ASCVD Plus” app by the American College of Cardiology, I highly recommend it. IDSA also has a mobile phone app that can be helpful to quickly reference infectious disease treatment guidelines.

4. Rotational assignments (Journal Clubs, Case Presentations, and Topic Discussions): Many of the students that I've spoken with wished that they had more practice with journal clubs and case presentations before going on rotations. If you’ve never done a journal club before, a nice place to start is the ASHP journal club template (found here). Typically, journal clubs consist of a handout that outlines the important concepts of primary literature. You could make a PowerPoint (some preceptors might require a PowerPoint on top of the handout), but it's definitely not necessary. Case presentations are a little bit trickier. Often, these will be the “final project/assignment” for many rotations since they’re considered to be more comprehensive. I always try to choose a topic that is a bit more unique than your typical disease states. For example, one of my case presentations was on a patient with iron deficiency anemia. It can also be helpful to stay away from topics that your preceptor is an "expert" in. That may sound counterintuitive, but if you can teach something to your preceptor and not be grilled by questions that require a super deep understanding (which they would otherwise have), you'll typically have a good experience. Other than choosing a unique topic, the best piece of advice I can give for case presentations is to NOT procrastinate! This leads us into our next pointer.

5. Procrastination: Ok, let’s be real. We’ve all procrastinated at some point in our lives.  In my case, it’s usually being a “productive procrastinator”. Have you ever found yourself suddenly just cleaning your room, the kitchen, the bathroom, or whatever it is that you clean? Or have you found yourself working on a project that’s not exactly related to your schoolwork, or even just organized your desk for an hour or two while the real schoolwork lies a few feet away from you untouched? If yes, then you my friend are also a productive procrastinator. During your last year of pharmacy school, it is REALLY important to make sure you’re on top of your work and projects and not push them off last minute. Don’t make the same mistake I made a few times during the year and pull an all-nighter to complete that case presentation. Procrastination is NOT worth the sleep deprivation and mental instability. Some rotations will provide you with a calendar that has all your projects and due dates laid out. Use that to your advantage and start working on projects so you’re not scrambling at the end trying to finish everything all at once!

6. The importance of self-care and burnout: I know, I know… you’re probably tired of hearing anything more about burnout and self-care, but I thought I’d still mention it because self-care is something that MANY students (especially pharmacy students) forget about. Burnout isn't fun in any way, shape, or form. Being able to recognize when you are burned out is super important and it lets you know when you need to take a breather or break. There have been multiple instances during my rotations where I could feel my motivation dropping to rock bottom. My stress levels skyrocketed and feelings of becoming overwhelmed were washing over me like there was no tomorrow. If you find yourself in the same (or similar) situation, definitely let your preceptor know! From my own experiences, all my preceptors have been extremely understanding of the current pandemic situation and know that burnout is extremely common nowadays. If you need to just step outside for some fresh air, or even go home early to rest, make sure you communicate that with your preceptor. Take some time each day to just do what you love to do! For me, it includes going out for a run or just spending a half-hour in the kitchen cooking and dancing to some groovy tunes. Whatever it is that makes you happy and gets your mind off work is a great way to decompress!

The above list of tips and pointers is definitely not all-inclusive. There’s still so much more I could talk about, but it’d probably turn into a book at that point. APPE rotations will be tough, I’m not going to sugarcoat it. That transition from didactics into direct patient care may be overwhelming. Once you start completing each rotation, however, you’ll get more and more familiar with how you function and work. I would say that in this last year of pharmacy school, I have learned more than I ever could have during my classroom years. This is because you’re applying your foundational knowledge to real-life practice. It’s going to take time to get adjusted to going on rotations every single day. You’re going to have moments of discomfort. Take these experiences and use them to boost yourself forward to become the best pharmacist you can be for your patients. I wish you the best of luck, and if you have ANY questions, comments, or suggestions I am always willing to help younger students!

Author Bio: Justin Shiau is a current PGY1 Pharmacy Resident at Northwestern Medicine Central DuPage Hospital. Justin graduated with his Doctor of Pharmacy degree from the Southern Illinois University of Edwardsville in May 2022 with a specialization in education. In his free time, Justin likes to run, cook, and game with his buddies. Connect with him via LinkedIn here!