A Novel Book Club Regimen

Marin Abousaud, PharmD
Oncology Clinical Pharmacy Specialist, Head and Neck Cancer
Emory Healthcare, Winship Cancer Institute
Atlanta, GA

I have been very fortunate to have encountered several inspiring oncology patients throughout my training and career as an oncology clinical pharmacy specialist. There is one patient in particular who has made a lasting impact on the way I practice today.

During my fourth year of pharmacy school, I had an outpatient oncology rotation in an outpatient infusion center in a community cancer clinic. On my first week there, I met an older patient who was newly diagnosed with an oral cavity tumor. While my preceptor was educating her on the chemotherapy regimen and supportive care measures, I noticed she was overwhelmed with emotion. Afterwards, I engaged her in conversation and tried to provide comfort about her new diagnosis and treatment anxieties.

She shared with me that her husband had recently passed away, and she had been very lonely and depressed. They used to read books together and have long discussions about them. Since she was coming in for treatment each week – and sometimes, several times per week – I convinced her that we should start a book club and discuss the chapters when she came in for her treatments. As I built rapport with her, I was able to make recommendations that were tailored to her care and convinced her to seek treatment for her depression. She trusted my supportive care recommendations for her nausea and tried her best to increase her water intake since I reminded her about it each time I saw her.

Week after week, it was evident her morale was improving. Whenever she walked into the infusion area and saw me, she had a huge smile on her face and started waving her book, expressing her excitement to begin our discussion. By the end of my five weeks, we were able to get through two books; one she had suggested and another I suggested. On our last day together, I expressed how grateful I was to meet her and how deeply she had impacted my journey. I will never forget this next moment – she began tearing up and stated that I was the only reason she looked forward to her treatment appointments and that my positive, supportive attitude was what uplifted her spirits and helped her through one of the darkest moments in her life.

It was then that I truly understood the impact pharmacists, especially within the oncology field, have on patients. We see patients during some of their most challenging moments, when the stress, anxiety, fear, uncertainty, and toxicities they endure can be very overwhelming for them. Taking the time to build relationships with patients, understand their wants and needs, and provide support for them during these difficult times allows us to provide the best possible care. To this day, I still have a copy of the books we read together, and they serve as nice reminders to remain the positive, supportive person and pharmacist that my patients need.

Discovering Inspiration and Independence as a Clinical Pharmacist through Patient Interactions

Raymond DeMatteo, PharmD
Clinical Pharmacy Specialist
Memorial Sloan Kettering Cancer Center
New York, NY

As trainees, we learn to optimize pharmacotherapy to ensure appropriate outcomes for our patients. What is not always expected is the emotional bond we form with them, and the technical and operational aspects of our jobs that allow us to act as advocates for them. I didn’t fully appreciate these concepts until I entered my postgraduate year two (PGY2) in oncology, where I encountered a memorable patient on my leukemia rotation.

My patient was a young man diagnosed with chronic myeloid leukemia who had been placed on dasatinib. His BCR-ABL transcripts fluctuated due to non-compliance. Two weeks before he arrived to our service, he was admitted to an outside hospital and was found to be in lymphoid blast crisis. After a complicated hospital stay, he was discharged on ponatinib and presented to our team for systemic chemotherapy.

When I met with the patient and his mother to review the chemotherapy regimen, I remember the worry in their eyes, but also how kind and friendly they were. After spending 30-40 minutes discussing the treatment, they seemed more at ease and expressed gratitude for the information. It was at this time that I inquired how much ponatinib they had left, and they informed me that they were almost out. I had the physician send a new prescription to his pharmacy, but issues arose when insurance was not able to process the prescription. I spent hours on the phone with the insurance company, insisting that the request be expedited. After calling daily for 5 days, the medication was approved, and we avoided any missed doses.

This victory seemed short lived as the patient developed complications to chemotherapy, and I was asked to research the use of an antidote to help further mitigate toxicity. Hours of work were spent assessing the proper use, dose, monitoring parameters and procurement of the drug. Fortunately, the patient improved with supportive care alone, and did not need the antidote.

I learned several lessons from this patient experience, the first being that our responsibilities as clinical specialists extend to the operational aspects of care to ensure our patients can get their medications in a timely manner. If I had not spent hours on the phone with insurance, he would have experienced a treatment delay. Furthermore, it is a reminder of how valuable we are to the healthcare team when chemotherapy complications occur. I had never before been put in a situation where I needed to formulate a plan of action to prevent further toxicity, and it served as a fundamental lesson that these instances occur frequently in our profession and our expertise is needed to ensure medication safety.

This patient will always stay with me, as it’s a reminder of the value pharmacists bring to the healthcare team. It is our role to ensure patients receive the best pharmaceutical care possible. It is interactions like these that drive us as practitioners to optimize patient care and serve as patient advocates.

A Humane Hello

Emmeline C. Academia, PharmD
Clinical Pharmacy Specialist, Hematology/Oncology
Beth Israel Deaconess Medical Center
Boston, MA

It was another busy afternoon in the gastrointestinal oncology clinic, where pharmacists provide drug information, toxicity checks, and patient education for oral and intravenous chemotherapy. I was three months into my postgraduate year one (PGY1) training and on my ambulatory medical oncology rotation when a physician asked me to provide educa-tion for a pancreatic cancer patient.

The initial plan was for neo-adjuvant chemotherapy and surgery, but the tumor did not shrink as desired. Both the surgeon and medical oncologist presented treatment options to the patient and they decided to try to get to surgery with a different regimen. Leaning on a pragmatic optimism, I took my education material and talking points and walked into the examination room to meet the patient and his wife.

I knocked, entered, and introduced myself, smiling and ready to lead the conversation with confidence. After a “Good afternoon,” I asked a quick and nonchalant but happy, “How are you?” His wife smiled in a subdued optimism, nervously anticipating the conversation. The patient looked down in forlorn disappointment before slowly lifting his head to muster a weak smile with a heavy-chested sigh. Both of their faces, for a second, expressed a slightly offended, “How do you think we are?”

Everyone has little pet peeves, and one of mine is using “How are you?” as a synonym to “Hello.” It’s my opinion that “How are you?” is not a salutation; if you are walking down a hallway without intent to stop and hear the response – it’s not meant to be a greeting. Now, enter my inner dialogue: “Really? ‘How are you?’ The phrase that irks you on a normal day? And to a cancer patient no less? Who just received news that treatment didn’t work, and who has had all of an hour to process this new information?”

After completing my inner conversation, I paused and re-grouped. I apologized for the promptness of my salutation. We chatted for a few minutes about their frustration and sadness around the lack of tumor response, alluding to a fear that the next round wouldn’t work and dancing around the idea of losing hope. He stopped to breathe, in tedious disbelief and ponderous cliché as he asked if this was normal: “Why me?”
“Some things we expect, but other things, we just don’t understand well enough yet.”
“Okay. Well, how will this be different...?” We talked about the new chemotherapy plan, side effects, and potential interactions with the long list of herbal supplements he had brought with him. Their questions were ad-dressed; and perhaps, after a little ambiguity was made clear, a little hope was reinstilled.

That day reminds me that the provision of healthcare, especially in oncology, is always a two-way street. We can get so wrapped up in providing information in our busy days that sometimes, we forget that someone has to receive it. This patient reminded me of the humanity in our work, that no matter how busy we are, our duty is to provide accurate information thoughtfully. This mindful engagement of our patients is part of the quality that an ambulatory oncology pharmacist provides. That day, my practice was re-framed with a simple but meaningful rule: make sure your patients are, and feel, heard.