Monday, June 30, 2014

Side effects

One of the interesting things about being on rotation is the strange things that are happening that are unrelated to my current actual day to day working experiences. In other words, rotations are supposed to teach me pharmacy things and other things I learn or skills I develop are mere side effects.

Since I am clearly procrastinating, here's a short list of my side effect lessons.

1. I do not especially like having a dog. I'm staying in a place with 2 big dumb dogs who are very sweet but also a nuisance. Compared to Fluffinella (our superior resident feline who is probably napping on a pedestal at home right now), these dogs are far too much trouble. One gets so excited to go outside that zie jumps 5 or 6 feet straight into the air. It is ridiculous.

2. Birds are weird. I dodge the chickens leaving my parking space in the very large driveway, then the ducks paddling in the ditch near the road before I leave the driveway, then the pheasant who likes to dart across to the other swamp at the first corner, and THEN there's a family of wild turkies a block away. The tom turkey likes to strut ever so slowly across the road while the hen and chicks just hover in the bushes JUST TO MAKE ME NERVOUS. I also commute passed a pond with 2 pairs of geese nesting in it that take their combined chicks for a stroll along the shoulder of the road every morning JUST as I drive by. Fools are just begging to be smashed and yet they appear to have at least 4 communal chicks. I'm unclear if they are actually aware of which chicks belong to which parents as they even have adjoining nests that I noticed on a walk last week.

3. I still don't like driving in city traffic. It is infuriating to just sit in the car on the road waiting. I don't mind the drive when the traffic moves but gridlock is too much. It is a shame that I can't arrange a carpool or take some kind of transit to this specific rotation.

4. It's very weird being a "grown up." I'm staying with a friend who's in her 50s and there's a resident child of hers who is not that much younger than me, say 5 years or so, yet I'm an "adult" and I feel compelled to do things like empty the dish washer and pretend/avoid knowledge of a variety of things (did I see that when my friend was out of town, there was an extra guest overnight? No, I have no knowledge of that per se because a whole group of folk was here when I went to bed and I saw nothing about any extra cars in the morning, it's a mystery!).

5. I still forget where I put my car all the time. I have learned to accept that I just need to park in the same place every time and not fret about it because I can only remember so many things. When I am in a strange parking ramp, I just take the reminder slip about where I parked with no shame anymore. Getting lost is silly if I can avoid it.

6. It will be important in the future to remember to keep a change of clothes either in the car or in the office in case of coffee-related difficulties that necessitate a change of attire.

7. I am pretty happy with my "right sized" lunches and I may translate that into unit dosing my dinners as well. (Aside: "unit dosing" is something that happens often in a hospital pharmacy, where a large bottle gets purchased and then each dose gets put into its own packaging so it is ready to be given OR where a special single dose package gets purchased.) Once a week or so I make something for lunches and portion it out into 400-600 calorie servings in a variety of jars. I'm finding that now that I'm a few weeks in, I am happy enough and survive the commute home with my stomach rumbling. I keep reminding myself that being hungry isn't a bad thing, just a part of life, and that I should adapt and that I WILL adapt in time. I haven't ventured onto the scale yet but I think I've lost maybe an inch at my waist thus far so that's something.

8. I am really lazy after work and will need to plan my daily exercise to happen BEFORE work if it is going to happen at all.

9. Sleeping remains crucial and I am going to go attempt to do some more of it. I still fail miserably at a sensible bed time but I am doing all right at getting up on time despite not enough sleep.

Monday, June 23, 2014

Living the lies

So let's talk about the truth. Clearly there are lots of truths and lots of levels of truth, and since we are here on my blog, you're stuck with the truth that matters to me right now, as much of it as I've figured out.

The obsession (or whatever it is) that I have with figuring out what truths I'm hiding and from whom is over a decade old now and in all honesty, it started with a crazy guy asking me a question that I had never considered before. What's something you think about but don't tell anyone else?

So here and now, the levels of lies in my life are multiple. I don't find this necessarily all bad but mostly a part of being a person. If we were capable of being totally honest the world would be remarkably different. All people can't handle the whole truth, whatever that might be. I think we catch glimpses of the truth about ourselves and about the world and maybe about divinity but we are incapable of grasping the whole truth.

Right now there are a few levels of lies that are playing out sharply in my life: the lies of omission where I fail to correct people's assumptions about me and the lies I tell myself that materialize as excuses are most notable. There's also the obvious set of lies that underpin this blog, the ones that hide my identity, obscure my location and my spouse's identity, the pictures I'm not posting, the significant but identifying things in my life I'm omitting, but I feel like these are among the lesser sins at the moment.

So the lies of omission. What's the first thing every single person in a pharmacy asks a pharmacy student they've just met? "What do you want to do when you graduate? Do you want to work in a hospital or...?" I'm still working on a good answer beyond "well, I don't really know." I have some ideas but I'm not sure enough to narrow it down to one of three very different paths. Later on, maybe a half hour into the conversation at most but sometimes less if the other person is lobbying for a residency as the best way to go, we come to the "oh I' sure you'll match somewhere" point. (Aside: pharmacy residencies are the hot new thing what with the crunch in the market where there are not nearly enough hospital jobs to go around for new grads who want them so extra credentials are required to get those entry-level jobs. There's an application process in the fall, interviews lasting a day in January and February, and the Match happens afterward. Last year 2/3 of people who applied actually matched and a small chunk of residencies didn't match so some of those who didn't match likely scrambled to get those spots filled.) The problem is much more complex than that of course. While technically I have limitless options to apply to the perfect residency anywhere, I am cautious and want to avoid moving if it's at all possible. It might be possible but it would mean a long commute and maybe taking a less than perfect residency position (if I could get it at all). I'm then at the corner where I could mention that I'm not applying everywhere or just anywhere because of my family and omitting it.

The assumption made by everyone in the pharmacy is that, like most pharmacy students, I have no children and probably no spouse either. Furthermore the assumption is that I'm young and immature and pretty innocent. For the most part I let this slide because I am pretty private and would prefer to be remembered for my work and not for my non-traditional student status. I have been joking about how I appreciate being called a kid and could my superiors please try to work that in a few more times, especially when giving me verbal feedback so I can bask in being a kid just a tiny bit longer? It's only a little bit of a joke though. I  am reveling in the last bit of youth I have left before being a professional. There is also a little bit of ribbing of my superiors who are only a year or two older than me to remind them that not all pharmacy students are such babes in the woods. Obviously many are lost little sheep but not everyone and perhaps they should watch the lumping of us all into the "silly little kids who know nothing" heap.

I also am wary of making plans because I know exactly how well my plans have worked in the past: hahahahahahahahahahah no. My plans were wrong, sometimes exactly opposite of what has turned out to be the right direction.

One of the books I have been assigned to read so far (aside from a vast swath of things on a certain pharmacy association's website, to the tune of 175 printed pages of very dense text) is about adapting to constant change and being ready to change when the time comes (and it was pretty hokey and I don't even know how to make sense of its combination of hokey and useful). One of the main characters reluctantly and eventually changes to take a new path and starts writing messages on the wall for the other anti-change character in the hopes he'll follow, and one of the things shocked me.

"What would you do if you weren't afraid?"

I realized that maybe my hemming and hawing and not committing to applying for a residency might be because I'm afraid I'll fail. Then I had this moment of clarity where I realized I have already failed so spectacularly that there is no failure that will top that. If I apply for residencies and I get zero interviews, there is no public failure at all unless I let on that I applied. If I apply and interview for a residency but don't get it, that's not a failure. Getting the interview is huge! If I manage to interview and then match, that's a few levels of spectacular. There is no failure at all except if I fail to try. If I weren't afraid, I would go for it with no hesitation at all. I would dig in, research thoroughly and find a good fit and then apply.

So now that I recognize the lie that's been playing out in my life, I will squash it.

The other big omission that keeps playing out is mentioning my family. They aren't around right now so it feels monumental to me to avoid talking about them because I've already set up a situation where I am away, probably for the best but it's HARD to be away. I sat in on an interview and one of the candidate's reasons for wanting the new job is to have a shorter commute and therefore more time with the kids. At the time, I sort of went, "Aww how sweet, more time with kids..." and didn't look further. Then I considered what would happen if I was the person being interviewed looking for a change for that reason. Would I be that candid? Would I have a different answer? What would my response have been if the candidate looked different (more masculine, more feminine or pregnant)? And what does it say about me that I don't know for sure if I would treat a job candidate of a different gender identity the same when exactly the same words were spoken? Big questions that I'm sure I will consider at more length later.

So this brings me to the second significant category of lies that's been influencing my life lately: the lies I tell myself. I turn these lies into excuses and the excuses fuel my laziness. Example: I am tired after I get home from rotation, the traffic psyches me out, I really just want to eat pizza and relax afterward. I use being tired as an excuse to avoid a whole host of things, from eating healthier (takes more time) to exercising (too tired and sore) to being social (too tired, too hungry to wait to see if anyone else is around for dinner, etc). Sometimes I make excuses for why I can't get groceries after work so I can justify getting a fast food breakfast.

Today I did pretty well for the first part of the day. I was tired when I got home and hungry on the way but I resisted getting a snack and then went for a walk after dinner. Then I walked an extra 5 minutes beyond my goal (one way, I'm just timing the walk out for now and hoping to make it back in rather than timing the whole walk) and made it back. Of course then I had an ice cream bar while surveying the freezer for tomorrow's lunch prospects, but up to that point I was really good! I squashed all my excuses and did it anyway. I chose to think about the things I don't have to do (have a second ice cream bar, eat a snack before dinner, take a nap or watch TV ) and to skip the excuses and get to doing what needs to happen.

The lie I tell myself the most often is "tomorrow things will be different" and a close second is "just this one (or once) won't hurt that much so it isn't a big deal." But I know that now and today I have the chance to change things. I will not change my rocking out to a song from a musical in the car reminding myself "there's only this, forget regret, for life is yours to miss... there's no day but today." I can change things now, today. I can stop buying the lie that tomorrow will cure everything and that once is harmless. Once is only in the moment - in retrospect, all those "just once" events pile up.

Today I get to choose to keep living the lies or to move beyond the lies I've discovered into uncharted territory, and I get to keep making that choice all day long and I get to start over again when I inevitably am human and imperfect.

Tuesday, June 10, 2014


Now that I'm on rotations, I imagine I will either post more because it's lonely or less because it's exhausting and busy. Or maybe more in conjunction with this next thing I'm up to.

After "what's your name?" and "where do you go to school?" the next question every person I've met so far on rotations asks is "what do you want to do when you graduate?" I know I've written about this before but I'm too lazy at the moment to go hunt up old posts. If you're a long-time reader or have bothered with my archive, this is not new ground just a new time.

There are three major pathways to very different sorts of careers after pharmacy school. One is a community pharmacist job, at one of those chain pharmacies would be typical. The upside is lots of interacting with patients and caregivers. The downside is lots of standing all day long and night and weekend shifts. The other most common is a hospital pharmacist job. It's rare that anyone in public sees a hospital pharmacist but every patient in a hospital who gets a medication has it double checked by a pharmacist. Instead of interacting with patients, most hospital pharmacists interact with doctors and nurses. The third route is what I'll describe as "other" and it includes managed care pharmacists who work for insurers or other entities that manage healthcare somehow, nuclear pharmacists who prepare the medications used to do radioactive imaging among other things, and ambulatory care pharmacists who operate in a clinic setting. When I started pharmacy school I had no idea what an ambulatory care pharmacist did and here's how I understand it now in a little example. Say Harry Potter goes to see his doctor and discovers he has diabetes and high blood pressure. His doctor orders some labs, schedules him an appointment to see a dietician, and a follow up visit in a few weeks after he sees the diabetes educator. In some practices (say that national one that's had long wait times in the news recently) at that follow-up visit, Mr. Potter would see a pharmacist to talk about his medications first and then the doctor after that, both in the clinic, often in the very same exam room with a hand-off between providers or sometimes (rarely) both with some overlap. Then the pharmacist would schedule a follow up visit sooner or later than the next doctor visit. In some practices, patients see the doctor once a year and the pharmacist changes medications at any point in between those annual visits with follow ups based on patient needs.

The job market for pharmacists is tight. After finishing a PharmD there is the option to do a year or two of residency. These are competitive to get (mostly) and are almost all focused on hospital pharmacy. Most people who do a year of residency stop there but a few go on to the second year or do two year combined programs. Jobs are split 60-65% community, 20-30% hospital, 5-10% other. In cities with a population over 200,000 people a residency is required to be considered for a hospital job in most cases and depending on the area it may be required in smaller cities too.

Of course it isn't so bleak as "there are no jobs unless you do a residency and only 75% of people who apply get one" overall. There are jobs in community pharmacies but not always immediately nice positions with a fixed home store or not without willingness to relocate. Ambulatory care is expanding as medical homes start to be a thing. Managing healthcare costs is similarly a growing area where more and more pharmacists are employed.

The areas I feel I have the most skills in are informatics and patient care of the sort that happens in an ambulatory setting. Informatics is the computer stuff that happens to make a pharmacy work so there are informatics pharmacists in all realms of pharmacy but mostly in hospitals since it's so complex to manage the wide range of patients in a hospital. To work in a hospital in particular would require both a first year general residency and a second year informatics residency (probably). Similarly ambulatory care would require either a residency for a year or two, or waiting a few years to start applying for jobs in that specialty area.

So then there's the residency debate. If my life were different and there were zero children involved, we would find the best residency program and move wherever to complete it. I think that if I had the whole nation to search and apply, I could find a program that would be a good fit and that I might match with (or be able to scramble for). But that isn't my life and I don't have unlimited flexibility. Given the kid's very poor adjustment the last time we moved, I think we can move one more time to a new school and that's it. So that doesn't exactly prevent me from looking at residencies outside driving distance of where I live now but it does mean we would need to be really sure about accepting a position that requires moving.

At the moment I'm getting ready to structure a period of discernment for myself so I can consider the options and figure out what's the right or most right path for now. The cool thing about pharmacy is that it's very possible to change specialties if you want at any point. Although it's rare for a community pharmacist to switch to being a hospital pharmacist, it happens occasionally. Discernment is something I've done before and I'm looking forward to planning it out. I'm going to do more prayer and meditation, read some sacred texts and some sacrilegious ones and probably some self-help books too, and make some lists. Then I will deliberate and consider the merits of each path and then reflect on them. At the end is some prayerful consideration and listening for cues and clues to point me in the right direction and then accepting whatever my heart and gut point me to.