Core Rotations

Internal Medicine (1 month)

This rotation is designed to provide residents with a broad training experience in managing acutely ill internal medicine patients admitted for diverse and complex medical management. The goal of this rotation is for residents to develop the skills and competencies in pharmaceutical care in the area of inpatient internal medicine, enabling them to effectively participate in therapeutic decision making, drug therapy selection, monitoring of acutely ill patients and discharge counseling. The active involvement of residents in screening patients' medication profiles for potential problems involving dosing, drug allergies, drug interactions, intravenous compatibilities and medication response, in addition to monitoring antibiotic therapy and any medication that requires additional laboratory monitoring, will help assure high quality patient care.

Integrated Practice Rotation (2 months)

The Integrated Practice Rotation is a 2 month experience within one of the pharmacy divisions - pediatric, oncology, or the adult medicine, emergency and surgery pharmacy division. During this 2 month experience, residents are expected to provide patient-care services within the division’s established team-based/integrated model of care. The resident will be exposed to and expected to perform a variety of roles and responsibilities of a pharmacist practicing in this model. This may include, but is not limited to: attending and actively participating in patient care rounds with the multi-professional team, performing order review and verification for assigned patients, participating in program-oriented services (such as: anticoagulation, therapeutic drug monitoring, readmission reduction and transition of care programs, or others), providing drug information and education, participating in patient safety initiatives, or performing any other functions expected of a pharmacist within the assigned division.

Leadership Collaborative Rotation (1 month)

The Leadership Collaborative Rotation (LCR) is a monthly collaborative experience required during the PGY1 residency that incorporates three areas of practice. Through this rotation residents gain experience regarding the medication-use process and medication safety, drug information and formulary management and an understanding of administrative and management, and leadership principles within a large teaching and research-oriented hospital and health-system. The focus of this rotation includes such areas as practice leadership, drug policy, medication safety, operations, pharmaceutical outcomes, clinical and investigational drug services.

Critical Care rotations (1 month)

One of the following rotations

• Cardiac Care
  This rotation is designed to allow residents to develop proficiency in the provision of care to patients encountered in the specialized area of cardiac intensive care medicine. The resident will be expected to build on the basic knowledge gained during other patient care rotations, while focusing intensively on the patients' cardiac and critical care issues. The resident will accomplish this by interacting with the multidisciplinary medical team during patient rounds and educational conferences, and by developing an understanding of the current application of drug therapy to various cardiovascular disease states encountered during rotation.
• Medical Intensive Care
  The medical intensive care (MICU) offers provides the residents with the opportunity to provide pharmaceutical care to the critically ill medical patient. The resident will join the interdisciplinary MICU team and will be directly involved with and responsible for drug selection, dosing, and monitoring. The patient population encountered frequently includes patients with multi-organ failure and complex medical problems. The resident will develop skills in the management of infectious diseases and the application of pharmacokinetics.
• Surgical Intensive Care
  There are two general surgical intensive care units: the Surgical ICU (SICU) and the Weinberg ICU (WICU). A rotation in either of these units enables the resident to provide care to critically ill surgical patients. In the SICU, patient populations primarily include trauma, abdominal organ transplant (kidney, liver, and pancreas), gastrointestinal surgery, and vascular surgery. In the WICU, patient populations primarily include gastrointestinal surgery, gynecologic oncology surgery, surgical oncology and endocrinology, urology, thoracic surgery, and otolaryngology. The resident will be a part of the ICU team, participating in daily patient care rounds to provide pharmacotherapy recommendations and drug information. Daily patient case discussions and frequent topic discussions will occur. The resident will develop skills in the management of infectious diseases, the application of pharmacokinetic principles, and various concepts in surgical critical care.
• Neurosciences Critical Care
  The neurosciences critical care unit (NCCU) is a 24-bed intensive care unit consisting of approximately 70% neurosurgical and 30% neurological critical care patients. The rotation is designed to expand on basic knowledge and clinical abilities gained on previous rotations, and to enhance the residents critical thinking skills. The resident will join the interdisciplinary team on daily rounds and be intimately involved with the optimization of drug therapy in this specialized patient population. In addition, residents are expected to provide educational services to the team through a variety of forums. Patient care discussions are held daily, and numerous critical care topic discussions are performed throughout the rotation. Disease states commonly encountered in the NCCU include: hemorrhagic stroke, ischemic stroke, hydrocephalus, brain tumor, traumatic brain injury, spinal cord injury/disorders, status epilepticus, epilepsy, guillain barre, and myasthenia gravis. In addition to a specialized focus on the neurosciences, the resident will gain experience in more general critical care concepts such as: sedation, paralysis, fluids/electrolytes, nutrition support, pharmacokinetics, hemodynamics, invasive monitoring, multi-system organ failure, infectious diseases, and mechanical ventilation.
• Cardiovascular Surgical Intensive Care
  The cardiovascular surgical intensive care unit (CVSICU) is an 18-bed unit that provides care for patients undergoing cardiovascular procedures such as heart and lung transplant, ventricular assist device implantation, extracorporeal membrane oxygenation, coronary artery bypass grafting, and cardiac valve repair/replacement. Residents completing this rotation will become skilled in care of the general critical care patient, as well as specialized care of the cardiovascular surgical patient. Daily patient care activities include pre-rounding on all patients to thoroughly evaluate medication- related issues, daily rounds with presentation of recommendations with the interdisciplinary team and follow-up regarding unresolved issues. The resident will meet daily with the preceptor for patient review and topic discussions such as management of hemodynamics, multimodal analgesia, neuromuscular blockade, postoperative atrial fibrillation, heparin-induced thrombocytopenia, and aortic dissection.

Ambulatory Care

A unique part of the program is the longitudinal nature of this rotation. The resident is provided the opportunity to develop expertise in the medication therapy management of chronic disease states commonly encountered in the ambulatory setting. These disease states include, but are not limited to:hypertension, hyperlipidemia, diabetes, asthma, COPD, dementia, and coagulopathies. The resident may spend time in the anticoagulation management clinic, the adult internal medicine clinic, and the post-discharge clinic (the After Care Clinic). Residents also assess the need for patient education, lifestyle modification, reinforcement, appropriate medical device use and technique, insulin titration or instruction, and drug therapy management. They will gain experience as a resource to clinicians by providing drug information, monitoring drug therapy for efficacy, completing cost comparisons, and making recommendations for potential alternative regimens to achieve optimal patient outcomes. Residents will complete two three-month ambulatory care clinical experiences. The resident will participate in clinic for one half-day every other week for each three-month rotation. The resident will work with the same preceptor(s), in the same clinic, on the same weekday during each three-month clinical experience.

Elective Rotations

Adult Hepatology Service

Adult Hepatology service is an elective learning experience for the Pharmacy resident. The inpatient hepatology service is also referred to as the "MEG" service, named after Mary Elizabeth Garrett. The medical team is composed of a hepatologist attending physician, a gastroenterology fellow, a clinical pharmacist, 2 junior assistant medical residents, 1 medical student (on occasion), a social worker, a case manager and a care coordinator clinical nurse. Patients are admitted to the service from the clinic (hepatology and transplant hepatology), ED, MICU, and HAL line transfer. Work rounds start at 9:00 am and the number of patients varies with a service cap of 12 patients and the possibility of one additional patient. Daily progress of all patients is discussed during the work rounds in the physician team room. Residents are not expected to attend multi-disciplinary rounds daily but are expected to help facilitate transitions of care.

Hematologic Malignancies

The hematologic malignancies service is responsible for inpatient care of adults with acute and chronic leukemias, myelodysplastic syndrome, and occasionally lymphomas or multiple myeloma. Common clinical scenarios include administration of anti-cancer therapies and supportive care. The rotation has a strong focus on therapeutic drug monitoring, infectious diseases in immunocompromised patients, and the use of investigational agents. The resident will attend daily rounds and is responsible for ensuring safe and effective medication use for a daily census of 10 – 20 patients. Other rotation activities include care coordination rounds, topic discussions, patient counseling, and inservice education for nursing, medical, and/or pharmacy staff. Educational opportunities include case conferences and morning teaching sessions with the attending physicians on service.

Antimicrobial Stewardship

During this rotation, the resident will spend their time working closely with the Antimicrobial Stewardship (AS) team. The AS team consists of 2 attendings and 2 ID clinical pharmacists. The patient care area is distributed throughout the hospital and not confined to a specific area. This rotation will provide an opportunity for residents to gain insight into the management of common infections and selection of initial antimicrobial therapy, antimicrobial utilization at our institution, and related antimicrobial hospital guidelines and policies. The resident will also improve their confidence and negotiation skills when discussing antibiotics choices with prescribers and other pharmacists. The resident is expected to assess appropriateness of antimicrobial therapy for assigned patients daily.

General Adult Infectious Disease Consult

Residents will round with the teaching service composed of an ID attending physician, two ID fellows, a clinical infectious diseases pharmacist, medical residents/students, and PA students/residents. Patients on service are generated through formalized consults from adult primary services (e.g. medicine, surgery, neurology, etc.). This rotation will provide an opportunity for residents to gain insight into management of various infectious diseases, primarily in immunocompetent host and also in an immunocompromised host such as HIV/AIDS. The resident is responsible for assessment of appropriateness of antimicrobial therapy, attending ID conferences, and joining interdisciplinary ID team daily rounds.

Inpatient HIV/AIDS

The inpatient HIV service, also referred to as the “Polk” service, is a primary medical team led by an infectious diseases (ID) attending. Patients admitted to the Polk service range from those with advanced HIV presenting with an opportunistic infection to well controlled HIV patients admitted for acute care issues. The service also admits non-HIV patients with complicated infectious diseases. This rotation will provide an opportunity for residents to gain insight into the management of patients with HIV/AIDS across the entire spectrum of the disease. The resident is responsible for assessing the appropriateness of all HIV and non-HIV related pharmacotherapy for all patients admitted to the Polk service. The resident will serve as an essential member of the interdisciplinary ID team and will attend weekly ID conferences. During this rotation, the resident should be able to establish a firm knowledge base in antiretroviral therapy as well as treatment of opportunistic infections and other complications of HIV.

Neonatal Intensive Care

The unit is a 45-bed level IV NICU that is capable of caring for neonates with a wide range of medical and surgical needs including prematurity, multiple births, congenital anomalies, necrotizing enterocolitis, respiratory distress syndrome and neonatal abstinence syndrome. Neonates may be born at JHH or transferred from other institutions with lower level NICUs by the Maryland Regional Neonatal Transport Service. During the course of the rotation, the resident is responsible for ensuring safe and effective medication use for all patients. Routine responsibilities include: reconciling medications for all patients admitted to the team, addressing formal consults for non-formulary drug requests, drug information, therapeutic drug monitoring, and anticoagulation management.

General Pediatrics

The purpose of this rotation is to have residents gain experience and proficiency for the pharmaceutical care of general pediatric patients. This will involve building the resident's knowledge on general pediatric disorders and related therapies and drug information resources. In addition, residents will develop problem-solving skills in this patient population through a variety of patient care experiences. Residents will be working with the pediatric house staff team on a daily basis by contributing to daily work rounds.

Pediatric Cystic Fibrosis

Throughout this rotation, residents will optimize health and medication outcomes of Cystic Fibrosis patients in both the inpatient and outpatient settings. The inpatient pediatric pulmonary service at Johns Hopkins Children’s Center serves a variety of populations including cystic fibrosis, asthma, chronic lung disease, and sleep apnea patients. The resident will ensure the safety and efficacy of all medications, answering drug information questions, analyzing pharmacokinetics, and providing discharge counseling. The resident will also participate in the outpatient Pediatric Cystic Fibrosis Ambulatory Clinic. Common responsibilities of the resident are seeing every patient by performing medication reconciliation, reviewing appropriateness of prescribed medications, processing refill and new prescriptions, answering drug information questions, assessing potential adverse drug reactions, and assisting with medication access. In addition to service-specific responsibilities, the resident will develop critical thinking skills and knowledge in the treatment and management of cystic fibrosis.

Pediatric Infectious Diseases Consult

This rotation will provide an opportunity for the resident to develop a knowledgebase of infectious diseases unique to the pediatric/neonatal population. The resident will gain experience with antimicrobial dosing in this patient population, as well as experience with pharmacokinetics. The resident is responsible for assessing all aspects of antimicrobial therapy for patients followed by the pediatric ID consult service, rounding with the consult team on a daily basis, and attending standing ID meetings. The resident is also expected to serve as a resource for drug information questions. Residents will work on developing their critical thinking skills through daily patient care activities, and will also work on presentation skills through various inservices/presentations that will be provided to the medical/pharmacy staff.

Pediatric Cardiac Intensive Care & Heart Transplant

The cardiac unit within the pediatric intensive care unit (PICU) provides care to diverse pediatric populations, including patients with congenital heart defects, post-op cardiac repairs, various cardiomyopathies, orthoptic heart transplants, and mechanical support (high frequency oscillatory ventilation (HFOV), continuous renal replacement therapy (CRRT), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VADs)). Pharmacists actively engage in a multidisciplinary approach with Pediatric Intensivists, Anesthesiologists, Cardiologists, electrophysiologists, dietitians, social workers, etc. to ensure acuity of care. The major goal of this rotation is to gain experience and proficiency in the care of these populations as well as developing problem-solving and critical thinking skills through a variety of direct patient- care experiences.

Pediatric Intensive Care

The pediatric intensive care (PICU) is a 40-bed tertiary care unit that provides care for diverse pediatric populations in The Bloomberg Children’s Center. The PICU incorporates the most critically ill patients ranging in age from premature neonates to young adults. Common diagnoses include respiratory distress syndrome, seizure disorders, solid organ transplant, oncologic emergencies, sepsis, organ failure, trauma, and burns. The PICU also cares for post-op cardiac repairs and patients receiving extracorporeal membrane oxygenation. The major goals of this rotation are to have the resident gain experience and proficiency in the medical and pharmaceutical care of PICU patients. This involves the development of a systematic approach to obtain pertinent patient information, as well as building the resident’s knowledge on common PICU disorders, related therapies, and drug information resources. The resident will be challenged to develop problem-solving and critical thinking skills through a variety of direct patient-care experiences.

Pediatric Nephrology

On the pediatric nephrology rotation, the resident will have the opportunity to care for children with kidney diseases in a variety of settings. The primary responsibility of the rotation consists of providing multidisciplinary care for patients on the inpatient pediatric nephrology team. These patients have a variety of kidney diseases, including lupus, nephrotic syndrome, chronic dialysis and renal transplant. The resident is also involved in seeing pediatric nephrology consult patients throughout the hospital and providing recommendations for patients with acute kidney injury, dialysis, hypertension, congenital anomalies of the kidneys and urinary tract, and other diseases. Finally, the resident will participate in outpatient kidney transplant clinic each week, providing medication reconciliation and participating in the transplant transition program by educating adolescent and young adult patients on medications and adherence, and helping them develop independence. The resident may also have the opportunity to participate in the Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) program, assisting with acute kidney injury prevention and surveillance for the entire Children’s Center. The rotation will focus on improving the resident’s knowledge of renal physiology, acute kidney injury, renal dose adjustments, chronic kidney disease, and principles of drug removal in dialysis. This knowledge will be useful when caring for patients of all ages. Additionally, the resident will develop skills and knowledge in pediatric pharmacotherapy.

Pediatric Emergency Medicine

The Pediatric Emergency Medicine rotation is designed to expose the resident to common pediatric emergency medicine disease states which include a combination of general pediatrics and pediatric critical care. As the pediatric trauma and burn center for the region, the resident will have the opportunity to participate in caring for these patients and work with the team in all critical care events to select, dose, and prepare medications. Residents are expected to collect relevant information from the electronic medical record, patient interviews, and outside sources in order to develop evidence-based therapeutic plans for patients in the pediatric emergency department. In addition, the resident will serve as a drug information resource and collaborate with the team to provide optimal care.

Emergency Medicine

The Emergency Medicine service is responsible for providing care for those patients in the Adult Emergency Department, and Emergency Acute Care Unit. During this rotation, pharmacy residents are expected to gain knowledge regarding the management of common emergency medicine disease states, which include a blend of critical care, internal medicine, and ambulatory care. Residents are expected to collect relevant information from the electronic medical record and patient interviews in order to develop evidence-based therapeutic plans for emergency department patients. Pharmacy residents will also be actively involved in all critical care situations, including all medical and trauma resuscitation, by providing assistance with medication selection, preparation and dosing. In addition, pharmacy residents will serve as a drug information resource for the interdisciplinary healthcare team.

Pharmacy Informatics

The experience involves planning, implementing, maintaining, and improving processes using the electronic medical record. Rotation content may vary depending upon Departmental and Organizational needs. Project management will be emphasized. The resident will work with a multi-disciplinary team to plan and implement new systems and review and measure the performance of existing systems. The resident will understand efforts and resources required for the maintenance of applications and hardware of existing systems. The resident will learn methods to obtain information from systems and be able to prepare reports necessary for operations.

Psychiatry

The psychiatry elective rotation offers the resident an opportunity to work closely with team members and patients focusing in the following specialty areas: Schizophrenia, Bipolar disorder, Depression, Anxiety disorders, Alzheimer’s Disease/Dementia, Parkinson’s Disease, and Alcoholism/ Dual Diagnosis and Substance Abuse. Residents also have the opportunity to attend cognitive behavioral therapy (CBT) groups, schizophrenia teaching rounds, and psychiatry grand rounds and observe electroconvulsive (ECT) therapy, psychiatric consult service and the psychiatry emergency department. In addition to psychiatric care, the resident will also be responsible for managing patients’ somatic care, providing group medication education and developing teaching topics.

Medication Quality and Outcomes

This rotation is designed to give the resident practical experience in data management, analysis, interpretation of results, and use of data to effect practice change. The resident will have direct exposure to and gain competency in Stata data management and analytic software. There will also be an emphasis on integrating strong design principles to design more meaningful and influential displays of data. The resident will gain exposure to the writing and publication process in the peer- reviewed medical literature. Additionally, the resident will gain exposure at the Johns Hopkins Bloomberg School of Public Health in the form of lectures, symposia, projects, and/or Center for Drug Safety and Effectiveness events.

Investigational Drug Service (IDS)

The goal of this rotation is to understand the role and contributions of the Investigational Drug Service (IDS) in the context of the Department of Pharmacy, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine and Bloomberg School of Public Health. IDS directly dispenses for many drug studies, coordinates studies in pharmacy divisions, and audits drug management and record keeping for studies in which the investigator holds the drug. The Johns Hopkins IDS comprises the Osler IDS (non-oncology) and the Weinberg IDS (oncology). The resident will gain an understanding of the new drug development process, regulations concerning the dispensing of investigational drugs, the pharmacist’s role on the IRB, and become familiar with the daily operations of a pharmacy-based investigational drug service.

Blood and Marrow Transplantation, Lymphoma and Myeloma

The Myeloma, Transplant, and Lymphoma (MTL) service is primarily responsible for providing care to patients that are in the process of receiving or who have received an autologous or allogeneic hematopoietic stem cell transplant or CART T-cell therapy. Patients with multiple myeloma or lymphoma are also admitted to this service to receive chemotherapy or care for complications associated with these disease states. The resident will gain experience managing infectious diseases in immunocompromised patients, providing supportive care to patients undergoing chemotherapy, and providing patient education. The resident will be responsible for attending daily rounds, monitoring drug therapy, and providing drug information to the medical team. The resident will meet with the preceptor daily to discuss patients and will cover topic discussions routinely.

Medical Oncology

The inpatient medical oncology rotation will provide residents with broad exposure to chemotherapy and oncology supportive care concepts affecting patients diagnosed with solid tumors. These include, but are not limited to oncologic emergencies, infectious complications, cancer pain, nausea/vomiting, and immune-related adverse events. This experience will also expose residents to resources oncology clinicians use to drive therapeutic decision making, and afford the opportunity to better understand how clinicians manage oncology while also balancing other chronic comorbidities. Patient care discussions with the preceptor will be held daily, and cancer or chemotherapy-based topic discussions will be held at least weekly throughout the rotation.

Addiction Medicine

The Addiction Medicine elective rotation engages residents in the care of hospitalized patients with substance use disorders (SUD), including opioid, alcohol, benzodiazepine, and stimulant use disorders, to name a few. Residents will round with the Substance Use Disorder Service (SUDS), an inpatient consultation service composed of a physician, nurse practitioners, a behavioral health specialist, a social worker, and peer recovery coaches. Residents will gain experience communicating with patients about substance use, managing acute withdrawal syndromes, initiating maintenance medications for SUD, designing analgesia plans for patients with opioid use disorder, and facilitating successful transitions of care at discharge. Daily activities include patient rounds with the SUDS team, development of care plans, communication of recommendations to primary teams, and documentation of services provided.

Pain Management/Palliative Care

The Pain Management/Palliative Care learning experience will provide the resident with the opportunity to focus on optimal pain and symptom management in patient populations on the Neurosciences Pain Resource Team or Palliative Medicine Consult Service. The resident will gain experience in acute and chronic pain management, symptom management, opioid dosing and equianalgesic conversions. The resident is responsible for assessment of patients’ analgesic regimen with regard to efficacy and adverse effects. Patients and caregivers interactions will occur on a daily basis as well as communicating recommendations to the primary service.

Advanced Heart Failure and Heart Transplantation

The Advanced Heart Failure and Heart Transplantation Rotation focuses on the optimization of drug therapy in this specialized population. The resident will join the interdisciplinary team on daily rounds. Patient care discussions are held daily, and numerous applicable topic discussions are performed throughout the rotation. Disease states and therapeutics commonly encountered on the HF/HT service are of both medical and surgical varieties, including, but not limited to the following: advanced heart failure, hemodynamics, inotropic support, mechanical circulatory support, heart transplantation, immunosuppression, and pathology related to heart transplantation. In addition, the resident will gain experience with concepts including: pharmacokinetics, infectious diseases of the immunocompromised host, thrombosis and hemostasis.

Medication Safety

During the Medication Safety rotation, the resident will work closely with the Medication Safety Team to gain experience with various methodologies used to measure medication-use safety, participate in the application of technologies that improve the medication-use process, learn and apply methods to promote a culture of safety, and analyze complex systems to identify and correct system flaws. The pharmacy’s medication safety team have hospital-wide responsibilities for identifying and helping to resolve medication use system flaws that endanger patients. System flaws are identified by reviewing reported medication errors, by proactively evaluating medication use processes, by reviewing the literature for reports of errors that have occurred elsewhere, and by searching for and implementing “best practices”.

Transplant Nephrology

This rotation will expose residents to kidney and pancreas transplant recipients who are more than six months post-transplant and admitted for inpatient care. The resident will gain experience managing a variety of disease states in this population including complications related to long-term immunosuppressive pharmacotherapy. The resident will be expected to closely follow patient drug therapy, actively participate in daily multidisciplinary rounds, and serve as a drug information resource to the team.