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Adapting to Unprecedented Circumstances
In the midst of a national pandemic, pharmacy schools face extraordinary challenges as they work to make alternate arrangements for rotations, determine how students will graduate on time and ensure that learning continues.
By Jane E. Rooney
The COVID-19 pandemic turned lives upside down for citizens around the globe. For pharmacy schools, as with most education institutions throughout the United States, this meant a drastic adjustment as administrators, faculty and students shifted to virtual learning arrangements for the foreseeable future. Although many institutions have experience with emergency planning for events such as natural disasters or short-term closures, a viral outbreak on this scale is unprecedented. “We never thought of a pandemic of this proportion,” said Dr. Wanda Maldonado, professor and dean, University of Puerto Rico School of Pharmacy, who is part of a COVID-19 Task Force appointed by the governor to provide guidance to the Department of Health. “This has taken a lot of effort from the task force. There were no protocols in place for guidance, as the spread of this disease is a fairly recent phenomenon.”
When it became clear in mid-March 2020 how quickly the virus was spreading, AACP joined several pharmacy advocacy groups in urging government agencies to adopt policy recommendations to empower pharmacists to support the nation’s response and assist patients. The four recommended measures were: authorizing test-treat-immunize; easing operational barriers to address workforce and workflow issues; addressing shortages and continuity of care; and reimbursing for services and removing barriers.
“A collaborative spirit is at work at the state and national level within pharmacy and also in our interprofessional community,” noted AACP CEO and Executive Vice President Dr. Lucinda Maine. “To have a substantive policy analysis produced and signed on by over a dozen national organizations in less than a week simply has no precedent. We have already seen the outcomes in terms of state pharmacy board waivers to address the needs we identified in that document. That is one of the most striking results of this collaboration.”
Maine added that AACP is striving to provide resources to individuals and institutions to help them through this crisis. “The pandemic has stimulated the most remarkable amount of cooperation, resource sharing and mutual support that I have ever witnessed,” she said. “From our co-hosting the initial series of webinars with ACPE for deans or their designates in midMarch to various sections and special interest groups using AACP Connect for problem solving and resource sharing, it is a testament to what wonderful people we have in the Academy.”
Here are the stories from several pharmacy schools around the country about how they made decisions and handled the restrictions brought on by COVID-19 in the early days of the outbreak in March. (This information was up to date as of press time in late April 2020.)
Unknown Scenarios Puerto Rico was one of the first U.S. jurisdictions to impose strict measures to try to contain the coronavirus, enforcing a strict lockdown that began on March 15. At that point, all didactic courses at the University of Puerto Rico School of Pharmacy transitioned to online platforms, said Maldonado. “For experiential education, we made some adjustments. We went through a process of reassessing when these experiences
would be offered and in which scenarios, since lockdown regulations are very tight. Our students were reassigned when we performed an assessment of the practice sites’ availability and students’ required experiences.” She expressed confidence that despite the pause in activity, graduating students will be able to meet their requirements to graduate on time.
She added that in many ways, the school and faculty are continuing with their academic duties. “Researchers from our school are allowed to go sporadically to continue with research investigations, so these are not affected, and they can continue with experiments that are ongoing. Some of them have external funding so they are allowed to provide continuity but while observing social distancing, with minimal personnel present. Currently, no students are involved unless absolutely required.”
The governor’s task force is considering protocols for pharmacists, physicians, long-term care institutions, nursing homes and other sites that need guidance in terms of prevention and mitigation of the pandemic. In addition to Maldonado, task force members include physicians of different specialties, epidemiologists and health services administrators. “The task force chair is the chancellor of our medical sciences campus,” Maldonado noted. “It’s a group of great variety that can provide input in terms of different types of expertise. For pharmacists, we have provided guidance in terms of how controlled substances should be managed as well as handling prescriptions given the updated DEA guidance and telemedicine regulations. We are also providing guidance on the use of hydroxychloroquine when deemed appropriate, and in order to preserve a supply for patients who use it for autoimmune diseases, among other pharmacy-related matters.”
In Seattle, which was one of the first areas in the United States to be affected by COVID-19, the University of Washington School of Pharmacy had to make quick decisions about how to move forward. “We had our first case back in January. Our first communication with students was Jan. 27,” said Dr. Jennifer Danielson, assistant dean, Experiential Education and Student Professional Development, and associate professor. “They did such a wonderful job taking care of that first patient and he was discharged. It gave Seattle a false sense of security. The school leadership sent information out to let people know the virus was out there and remind our students to follow hospital policies and procedures. We didn’t feel we needed to add extra layers of guidance. We reminded preceptors to make sure students knew what was going on. Then in late February it started blowing up.” At that point, she said, the school went into crisis management mode.
“We got a call from the first hospital [in King County] that had gotten hit really hard. They were the first to say that all the students have to leave,” she continued. “The pharmacy department was sad because they wanted to keep students. Then we started going into contingency mode. Every hour of every day over the next three weeks—we couldn’t seem to get ahead of it and make effective decisions about what to do for students. Our dean got involved, who has an advisory committee with representatives from many of the hospital
“Learning how to operate with this anxiety and uncertainty is the life of a healthcare professional. We’re scheduling a workshop with a mental health counselor to help [students] sit with this and be able to talk about it.” —Dr. Jennifer Danielson
systems. We got an agreement from the lead pharmacy directors to keep our students as much as possible. After a while some still found they had to let the students go. Our medical and nursing schools decided to take their students off rotations. They have more leeway in accreditation standards. This put pressure on us to remove our students. Our university hospital pharmacy department was the last one to let students go.”
Eventually the university hospital was able to set up remote access for student pharmacists on required rotations, allowing them to do daily check-ins with preceptors and do case presentations remotely. Danielson took on 14 students who are doing an elective experience, which will involve research projects with faculty or work as teaching assistants to help with online courses.
A major challenge, she noted, has been getting messaging out. “The amount of time it takes to draft communications to students, faculty and preceptors is amazing. We quickly realized we needed to have a consistent message, needed to run these up the chain. We would spend hours drafting emails, getting them vetted, then have new information come in and have to scrap it and start over.” Once administrators realized that some messages were getting lost in the sea of emails, they began weekly Zoom meetings with the dean and students, which helped get students’ questions answered.
Most student pharmacists are cooperative and understanding and simply glad to be graduating on time, Danielson said. Some are anxious and worried about exposure to the virus. “The uncertainty is a life lesson for them. Some want us to just call off rotations,” she explained. “In most cases we’ve been trying to counsel them through this. This is what life as a healthcare professional is. This is the calling we have. Learning how to operate with this anxiety and uncertainty is the life of a healthcare professional. We’re scheduling a workshop with a mental health counselor to help them sit with this and be able to talk about it.”
Sharing Ideas At the University of Pittsburgh, the first decision made was to extend spring break, which began on March 9, by an extra week. That provided the School of Pharmacy an opportunity to train faculty to use web-based resources and prepare for remote teaching, said Dr. Melissa Somma McGivney, professor and associate dean for community partnerships. “We quickly learned how to use remote teaching tools,” she said. “Faculty are utilizing the teaching technique that best matches the content of the course. We were communicating daily with our APPE students on rotation.”
Frequent, short communication was important during the initial adjustment period. In terms of APPE rotations, the three-person experiential learning department was critical in getting new processes in place. “Our dean was part of many conversations with ACPE and AACP about how students meet hours during this time,” McGivney noted. “That guidance has allowed us to provide some remote experiences where the students were no longer able to stay on site because of the decision of the organization or there was some reason the student couldn’t stay. Some are able to continue with experiences as planned, but for those who are not, we
have a hospital/clinical APPE that is run by faculty member Dr. Pamela Smithburger. I’m working with our team leading our community APPE remotely. We’ve partnered with independent pharmacies in western Pennsylvania that happened to be owned by alumni, so that’s been terrific. They were seeking additional support. We have eight students completing a remote APPE. They are doing projects to assist pharmacists: writing protocols, condensing information, supporting call-based patient care, which they can do remotely, also working on some advocacy projects to support communitybased pharmacists.” All students are now positioned to meet graduation requirements.
The School of Pharmacy is leading the ACT (AcademiaCPESN Transformation) Pharmacy Collaborative, an operational learning collaborative between 85 colleges and schools of pharmacy and established clinically integrated networks of community-based pharmacies. The collaborative mobilizes stakeholders and resources to support and facilitate implementation of community-based pharmacy care. A webinar in mid-March brought together faculty and independent pharmacies that were concerned about not having enough staff.
“We’ve put together opportunities for independent pharmacies to raise their hand if they need help and share with schools if they have students who want paid internships, volunteer hours or IPPE or APPE experiences,” McGivney said. “We are also working on another webinar [which occurred in early April] to bring together leaders from national pharmacy organizations to share legislative and advocacy action supporting community pharmacy transformation.” The collaborative connects schools to make sure messaging about IPPEs and APPEs are in line with each other and to share resources among faculty. She added that pharmacy school deans throughout Pennsylvania are communicating to talk about advocacy issues.
Dr. Trish Devine, associate professor, pharmacy practice, and director of interprofessional education, Butler University College of Pharmacyand Health Sciences, said that she definitely saw collaboration among schools as they worked to find solutions in the initial weeks of the coronavirus outbreak. As current chair of AACP’s Experiential Education section, she helped facilitate several webinars in late March to provide time for members to ask questions and share possible solutions and innovative ideas for APPE and IPPE requirements during difficult times. “We had 80-110 attendees each session,” she said. “Right there it shows that we’re such an active section and want to help each other, so that was great to see.”
For the many schools that do above the APPE 1440-hour ACPE requirement, she continued, schools have taken the extra hours that students obtained earlier from previous rotations, looked at overlap of competencies and objectives that would meet the competencies of the core required rotation that was shortened or cancelled and applied those hours toward the needed rotation and total hours. “Out East, it seems like they have been hit the hardest. A few schools that cancelled their last block were able to make up the deficit using previous hours or looking at virtual things they can do.
“For the students it is a unique opportunity to learn how to rise to the occasion, how to demonstrate their value. Even if all other establishments close, pharmacies continue to provide services. They have established protocols and have not stopped serving the population.” —Dr. Wanda Maldonado
Some schools said they have developed virtual drug information rotation for students who needed hours. One school in Florida found that there were COVID-19 call centers that needed volunteers so they were able to connect with a faculty member and students were volunteering at the call centers.”
Devine acknowledged that the hardest rotation to complete remotely is the hospital/health system. “That’s the main concern—trying to complete those hours and keep our students safe,” she noted. “Most hospital/health system sites are no longer taking students. Most if not all ambulatory care rotations have gone virtual. At some sites students have access to patient health records, attend virtual rounds, write up the cases and communicate with patients through telehealth via the phone. Other sites where students did not have access to patient records, preceptors de-identified the patient information, sent it to the student for the case to be worked up remotely and would connect with the preceptor to discuss and meet with the patient through telehealth.”
Coping With Uncertainty The next challenges facing many schools are related to the new APPE students (class of 2021) and summer IPPE students, Devine said. “Most programs start their rotation blocks in May or June, so people are either delaying the start of a block so they will have one less block off during the school year or rescheduling any that were scheduled in a hospital/health system to block three and putting everyone in a community or non-hospital rotation for block one or two,” she explained. “A lot of schools do IPPEs in the summer. For institutional IPPEs, we have delayed the start of those rotations to bock two. Some schools with block course schedules are discussing moving a fall didactic course to a summer online course and using the time in fall for an IPPE rotation.”
Butler is among the schools that, if IPPEs are not able to be completed this summer or during winter break, would have students complete an IPPE next May (2021), and the advanced rotation would be delayed one month. “That’s our fallback plan,” she added. “Winter break is another opportunity, but that’s less than four weeks for us. But we are looking at chunk of time during winter break. We put a task force together. For IPPEs, those students who have had experiences perhaps as interns, we’re looking at developing a standardized way for them to test out of hospital IPPE hours. The Experiential Education Section developed a task force to develop a guidance tool for schools to use to verify and document students with extensive hospital experience who have met desired competencies and outcomes and can opt out of those hours. They can obtain the hours in an area that is available for the student during this difficult time. If you can get some of your students to test out, it frees up slots for those students who need the hospital experience. Some schools are also doing simulation for IPPEs up to 60 hours. Now that hospitals might not take our students, we’re looking back at our curriculum to see what experiences in labs would count under simulation toward a hospital rotation. That will help decrease the number of hours students need in a hospital.” She noted that administrators are being innovative and creative coming up with ways to meet competencies; one school plans to do a mock IPPE in the fall.
With spring being the biggest time for onboarding requirements such as basic life support, Devine said it presents another difficult challenge since those are hands-on courses. “Some schools are contacting their sites to see if they would accept students receiving the classroom-only portion of the basic life support course and complete the hands-on portion once it is available,” she said. “Students would often go to fire departments or training centers for their hands-on skills test. At this time that’s a challenge. Required screenings and vaccinations is another challenge as labs and medical offices are not taking well visits. Butler requires IGRA TB tests completed on students. This potentially could delay rotations as only a few of our students completed this requirement through their place of employment. Experiential education offices are having to complete a lot more work during an already busy time of year but it seems like faculty from schools of pharmacy have been willing to help our offices with the extra work. Everyone is sharing what they’re doing, their resources, so we don’t have to reinvent different assessments.”
Washington’s Danielson also witnessed colleagues in her region sharing ideas and resources. “I started talking to other experiential education people,” she recalled. “We have a consortium here in the Northwest. Mostly it’s been sharing information, how are you handling this…the frenzied pace was amazing.” She said there is widespread acceptance that remote options have to be okay in this unprecedented situation. “If your hospitals are willing to set up remote access for patient care records, that does allow a student to do patient care activities,” she advised. “We found it easier than we thought it would be to set up. That allows students to finish out the rotation that started face to face. You do end up having students you have to pull off and do alternative experiences. Reach out to your board of pharmacy. We got agreement that they were okay with this. Pharmacists aren’t always face to face with patients right now anyway, so you do the best you can. I referred to it as the grief process. It’s not going to be perfect. These wonderful schedules are just not going to happen. None of our lives are the same anymore. Get through the grief process to acceptance to make the best of what you can do.”
Maldonado in Puerto Rico said the experience has underscored the need for pharmacists and has provided some good reminders for student pharmacists. “For the students it is a unique opportunity to learn how to rise to the occasion, how to demonstrate their value,” she said. “Even if all other establishments close, pharmacies continue to provide services. They have established protocols and have not stopped serving the population. They have been key.” P
Jane Rooney is managing editor of Academic Pharmacy Now.
University of the Pacific Faculty Researcher Awarded $1.15 Million NIH Grant Research focused on the differences in the way males and females process GHB could lead to better understanding of overdose risk.
Dr. Melanie A. Felmlee, an assistant professor of pharmaceutics and medicinal chemistry at University of the Pacific’s Thomas J. Long School of Pharmacy, has received a four-year, $1.15 million grant for research that focuses on the differences in the way males and females process GHB. The grant is from the National Institutes of Health Support of Competitive Research (SCORE) Program for her project “GHB Toxicokinetics: Role of sex hormone dependent monocarboxylate transporter regulation and potential for altered overdose risk in transgender men and women.” The SCORE Research Advancement Award is co-funded by the National Institute of General Medical Sciences and the National Institute on Drug Abuse.
“This grant provides the support to significantly enhance and accelerate the research conducted in my lab at University of the Pacific,” Felmlee said. “With this research we hope to understand why GHB toxicity is different in males and females, inclusive of all atrisk populations.” Felmlee is passionate about bringing awareness through her research to underserved populations that are at risk.
“I think when we design any study we should be inclusive,” Felmlee said. “While we are trying to look at the whole spectrum, we are focusing on the transgender population, which has largely been overlooked in GHB research studies.” The research has the potential for broader application. “The monocarboxylate transporters I study are also involved in targeted therapeutic strategies for oncology, fertility studies and immune suppression,” she continued. “Changes in these transporters in response to sex hormones has the potential to impact these broader fields of research.”
Felmlee’s research focuses on the role of sex differences on transporter regulation and toxicity of drugs. Her research on GHB suggests females are protected from toxicity, compared to males, because of the hormones estrogen and progestogen. This research will look at specific proteins that transport GHB across cell membranes and their regulation by sex hormone therapy.
“The transporters are regulated by sex hormones,” Felmlee said. “They are critical for determining how one’s kidney functions in terms of removing the drug. What my graduate research assistants and I have found is females at certain times in their reproductive cycle are more protected from GHB toxicity and they were able to remove the drug faster. The transporters are the key to figuring out why there are the differences associated with the sex hormones.”
GHB, or gamma-hydroxybutyrate, is a central nervous system depressant clinically prescribed to treat the medical conditions narcolepsy and cataplexy. It is also an illicit drug taken for its calming and euphoric effects, which make it a popular drug of abuse. In
photo: University of the Pacific “What my graduate research assistants and I have found is females at certain times in their reproductive cycle are more protected from GHB toxicity and they were able to remove the drug faster. The transporters are the key to figuring out why there are the differences associated with the sex hormones.” —Dr. Melanie Felmlee
