Student Presumptions
As if navigating rotations with real patients and highly esteemed preceptors is not enough, rising fourth year pharmacy students have the added pressure of coping with the new normal resulting from coronavirus disease 2019 (COVID-19).

Nerves set in for these fresh, new students as they would for any other student. Internally they think, “Do I know enough? Could my decisions harm a patient? Will I be ready for my future as a pharmacist?” Yet, in March 2020, new concerns arose.

Like fourth year pharmacy students across the country working in this new normal, I also wondered, “Will I be exposed to coronavirus on rotations? Could I bring the virus home to my family? Will competitive rotations still accept students? Will I have quality experiences given virtual connections to preceptors and patients?”  

Personally, my focus is on developing clinical skills, ensuring a competitive and challenging experience to prepare me for residency, and optimizing virtual education. Point-of-care testing, patient counseling, medication reconciliation, and building rapport with patients and preceptors are all skills to be refined the last year of school.

I am afraid I will not be able to practice consistently taking blood pressure, monitoring a pulse, or testing blood sugar on patients during the 12 months before becoming a “real” pharmacist. I am worried about miscommunication with a patient who cannot see my body language or facial expressions and vice versa during counseling sessions.

I am concerned about developing meaningful relationships with preceptors who have the ability to make or break connections for me in the future. I am troubled with the thought that COVID-19 will make me less prepared as a new pharmacist.

The Experience
I received the first draft, then the second, then the third, and finally the latest draft of my rotation schedule. It changed 3 times before rotations even began, as hospitals were limiting their availability to accept students.

Luckily, I was assigned 6 of my 8 rotations at academic hospitals, but still did not receive important rotations, such as critical care, in the final rotation schedule. Will residencies understand our situation?

Regardless, I was able to start my advanced learning experiences in the Emory Hepatology Clinic, specifically working with hepatitis C virus (HCV)-infected patients. Although some of my concerns came to fruition, such as not seeing patients face-to-face, I am surprised at the opportunity to gain more knowledge about specific patients and tailoring their care.

For instance, patient appointments are now through telehealth, so most patients are at home video-calling our physician assistant and pharmacist. With this virtual window into their homes and surroundings, we are better able to grasp the reality some patients live in and the associated challenges.

These challenges include limited organization with a concern for losing medication bottles; limited transportation options to a clinic or a pharmacy; lack of resources to pay for expensive treatment, labs, and appointments; and lack of technology to connect appropriately to their care team.

These factors, which can certainly affect outcomes, are rarely discovered when patients are seen in the same clinic setting, in which disparity and differing access to care among patients can be easily overlooked.

Fortunately, I have rarely been separated from my preceptor in my current clinical rotation. We are still able to meet every week, work up patients, present topic discussions, collaborate on new projects, and build a professional relationship.

Although we are behind masks and I miss seeing facial expressions as people speak, I feel I am still getting quality time with my preceptor and quality advice for the future; however, telehealth alters my clinical experience in some ways.

For example, I cannot provide in-depth patient counseling of other disease states unrelated to HCV that arise from bloodwork typically drawn and discussed the day of the appointment. To offset this, my preceptor makes a point of discussing broader topics with me so I can gain comprehensive knowledge, even if the application facet is lost.

Comprehensive education has not been lost, however, comprehensive application, such as point-of-care testing, still proves to be a limitation.

Collaborative Adaptability
Just as health care students experience new pressures resulting from COVID-19, so do preceptors. They have a shortened time frame to alter their entire rotation to accommodate virtual learning.

As expected, not everything is going to be perfect and kinks have to be worked out as the year progresses. During this time, flexibility is key.

My preceptor, who is very open to feedback and willing to adjust, has been able to expand my already limited experience. She has changed our follow-up calls with patients from phone calls to telehealth video chats, in which we can safely talk with patients without masks, see facial expressions, build rapport, and spend more time counseling and updating medication lists.

Just as she was agreeable to change, I was also asked to be open-minded. I was challenged to participate in video chats with the physician assistant and patients alone, offering my recommendations through an online platform. At times, it was hard to know when to interject so I was not accidentally interrupting someone else.

But overall, the physician assistant and patients seemed to welcome my input despite quick 15-minute distant connections. Although patients and providers everywhere experience some barriers in telehealth, benefits have been shown as digital access has increased medication adherence through SMS text message support and care is more accessible regardless of location.1

Adapting more digital care options in more health care settings can open new opportunities for providers to care for patients. Through a willingness to be adaptable, I no longer feel like I will be less of a pharmacist. Instead, I will be a pharmacist with new skills that former students never had the opportunity to develop.

I can communicate with patients and other providers on an interprofessional team in an effective, meaningful manner through a computer screen. Although restrictions resulting from COVID-19 created a different learning experience than what I anticipated, I am seizing every unanticipated opportunity for effective growth and change in this new normal. 

Precepting Perspectives
COVID-19 has changed the world in which I live, work, and teach. Precepting an ambulatory care rotation at an urban, academic medical center in the midst of COVID-19 has been marked with challenges, innovative adaptations, and creative solutions to maximize pharmacy students’ learning.

Although challenges remain throughout the foreseeable student rotations, including the absence of face-to-face patient visits, I focus on teaching principles and concepts that are translatable regardless of communication platform. Pharmacy students are learning how to build rapport with patients and providers in a virtual environment, provide effective recommendations and counseling, and adapt quickly depending on the course of conversation in telehealth visits.

Virtual home visits with patients enable us to observe their surroundings, evaluate potential barriers, review medication bottles, and tailor conversations accordingly. For patients who cannot access video calls, learners are growing in their communication abilities via phone calls.

Although students expected to make face-to-face recommendations to providers, COVID-19 has created another opportunity for flexibility and growth. Interventions are communicated to provider teams via phone or video call, or in written form based on provider preference. 

Students’ flexibility and adaptability when making recommendations based on provider preference have been impressive. Finally, the constantly fluctuating environment in which we operate can create a sense of uncertainty within learners.

Creating a safe space for learners to vocalize the pros and cons of the rotation experience is crucial for preceptors to make adaptations needed to maximize learning. COVID-19 has created unanticipated opportunities for pharmacy students to rise to new levels, grow in confidence, develop translatable skills in a 100% virtual environment, and be on the forefront of changing the way health care is delivered forever.

About the Author
Stephanie Watson, UGA College of Pharmacy, PharmD Candidate, Class of 2021; Dean, Student Advisory Counsel 

References
  1. Badawy SM, Radovic A. Digital approaches to remote pediatric health care delivery during the COVID-19 pandemic: Existing evidence and a call for further research. JMIR Pediatr Parent. 2020;3(1):e20049. doi:10.2196/20049.