Before my internship with RxPharmacist, I really had no idea what was possible with medical writing in the field of pharmacy. Now I’ve learned that it can really just be whatever you make of it. If you’re interested in a certain aspect of pharmacy, no matter how niche, there’s bound to be others just like you who are willing to read your work on it. I personally am interested in compounding and veterinary pharmacy, and was able to work on RcPharmacist’s first compounding guides!
The biggest thing I appreciated about this internship is how mutually beneficial it is. I got to work on projects that interested me and was given the opportunity to improve my own writing skills. RxPharmacist got to have content by pharmacists, for pharmacists. Everyone in the field of pharmacy benefits from the work put out by RxPharmacist. Like pretty much every new graduate, I had to also study for the NAPLEX and MPJE while working the internship. They understand this and will work with you and your schedule to make sure you feel comfortable and are successful!
Another thing I greatly enjoyed about the internship was the mentorship and networking that happened on the side. My mentor acted as the editor for my guide, and was always supportive and willing to give feedback. They try to match your mentor to your interests, and while my interests were sort of niche, my mentor was still a great source of information and mentorship. One of my mentors knew other pharmacists who were currently working in the fields that I’m interested in, and helped me connect with them to further network. I had some of the nicest mentors a new graduate could ask for.
In healthcare, collaboration and the sharing of information is vital to the expansion of knowledge. Different types of studies are conducted to confirm or build upon key concepts, such as the efficacy of a drug, the safety of an intervention, or the superiority of a specific treatment. In this blog, we will briefly review different study types that are used to answer clinical questions in the healthcare setting.
Quantitative studies1
Clinical guidelines are based upon evidence-based medicine (EBM), which is primarily derived from quantitative studies. Quantitative studies can either be descriptive or analytical.
A descriptive study does not try to establish a relationship between variables, and instead, simply describes the data that was found. Descriptive studies include case reports and case series.
An analytical study tests a hypothesis in a group of people to determine if there is a specific cause or relationship between variables. A hypothesis can be tested one of two ways: through the use of an intervention (an experimental study) or by observing the effect without directly applying an intervention (an observational study). Analytical studies include case-control, cohort, or randomized controlled studies, as well as those of a factorial design.
Below the different subtypes of studies are summarized.
Some studies pool together information from a variety of quantitative studies. Meta-analyses focus on pooling data to conduct further statistical analyses with increased power to support conclusions5. Forest plots are a tool typically utilized by meta-analyses. A systematic review focuses on answering a clinical question by summarizing data from other studies, without doing a separate statistical analysis5.
Qualitative studies6
While quantitative research is needed to justify consensus for EBM, qualitative studies are a major component of health care practice, particularly in the fields of academia and community health. If you are part of a non-profit organization looking to apply for grant funding, qualitative data can help to justify the needs of your population of interest.
The methodology of qualitative studies is based upon the information needed.
The _________ qualitative method…
asks the question(s)…
Phenomenology
How do people experience a certain event?
Grounded theory
What is the theoretical framework for a particular behavior, thought process, etc.?
Ethnography
What are the important cultural aspects of a particular community?
Historical
How can the past events affect the future for this group?
Narrative inquiry
What are the unique perspectives or lived experiences of this specific (often marginalized) group of people?
Action research
What approach does this specific (often marginalized) group of people propose for addressing groups like themselves? How can we get this group involved in the process?
Case study
What is the experience of a particular entity (individual, community, organization, etc.)?
Methods for achieving these types of studies are focus groups, interviews, surveys, and observation.
These study types can help to answer various questions within the healthcare setting. Although each type has the ability to elicit different information and outcomes, they all share in the common goal of expanding knowledge, and ultimately, improving patient care.
-Gabriela O., 2021 RxPharmacist Intern
References:
Ranganathan P, Aggarwal R. Study designs: Part 1 – An overview and classification. Perspect Clin Res. 2018;9(4):184-186. doi:10.4103/picr.PICR_124_18
Ranganathan P, Aggarwal R. Study designs: Part 3 – Analytical observational studies. Perspect Clin Res. 2019;10(2):91-94. doi:10.4103/picr.PICR_35_19
Aggarwal R, Ranganathan P. Study designs: Part 4 – Interventional studies. Perspect Clin Res. 2019;10(3):137-139. doi:10.4103/picr.PICR_91_19
Aggarwal R, Ranganathan P. Study designs: Part 2 – Descriptive studies. Perspect Clin Res. 2019;10(1):34-36. doi:10.4103/picr.PICR_154_18
Haidich AB. Meta-analysis in medical research. Hippokratia. 2010;14(Suppl 1):29-37
Qualitative study design: Qualitative study design. LibGuides. https://deakin.libguides.com/qualitative-study-designs. Accessed August 20, 2021.
My initial plan post-graduation was to find a retail pharmacy position as soon as possible. At the time, I was not working as an intern and was relying heavily on being able to take my board exams early. An opportunity to work at RxPharmacist was presented to me around the same time and I took the chance to develop skills that I otherwise would not be able to gain.
I worked on the first RxPharmacist Retail OTC guide with my preceptor. I was able to gain skills in content creation, medical writing, and professional development. The entire team was very supportive of each other, and communication was excellent.
At first, the project was daunting, given the scope of the guide. In addition, I also was studying for the NAPLEX and MPJE. However, with encouragement and support from the RxPharmacist team, I was able to overcome any obstacles. I am very appreciative of the independence that interns are given as I was able to choose my work schedule and even deadlines.
Overall, the RxPharmacist Internship has made me more confident in my own abilities. This internship has not only allowed me to improve myself, but also to give back to the profession.
All about writing- RxPharmacist Internship Testimonial
Throughout my experience in the world of health care, I’ve learned that one of the most important skills a clinician can have is writing. I have discovered that the pharmacists and physicians who can expertly navigate a patient case and process large amounts of data are the same ones who have published numerous papers and have excellent writing/technical skills. Throughout pharmacy school, I have sought to fine-tune my writing skills by joining and later becoming Editor-in-Chief of EMSOP Chronicles, a student run newspaper service for the Ernest Mario School of Pharmacy. Additionally, I participated in a rigorous research project to test the effects of sulfur mustard on the corneas where I learned valuable skills in writing a scientific thesis.
After graduating pharmacy school, I sought to refine my writing skills further by taking on new challenges and accepting an intern position with RxPharmacist. My job was to create a study guide and practice questions for the New Jersey Multistate Pharmacy Jurisprudence Examination (MPJE). This opportunity was especially educational as I was able to transition my writing skills from scientific/technical writing to study guides that can be easily read and understood. The amazing and supportive team at RxPharmacist gave me the necessary resources to guide me in creating the best version of my study guide. With their help, I had the opportunity to assist students across New Jersey with not only passing but excelling at their pharmacy licensing exam.
I am very thankful for RxPharmacist for giving me the opportunity to learn, make mistakes, and cultivate my writing skills which ultimately makes me a better clinician. My goal is to progress further and build on my skills by continuing my education at the Robert Wood Johnson Medical School. I believe that by entering medical school, I will find more opportunities to write and gain new perspectives to write about.
-Musab S., 2021 RxPharmacist Graduate Intern
Rutgers University, Ernest Mario School of Pharmacy, Class of 2021
The RxPharmacist internship program is an absolute must for anyone that feels even the slightest pull towards pursuing a pharmacy career that is non-traditional. Not only do you get paid to study, you get daily interactions with an army of mentors ready to help you with networking, job hunting, CV writing, and LinkedIn polishing.
The RxPharmacist team hosted many personalized workshops to help the interns transition from student to pharmacist, and more importantly, succeeding in their first job right out of school.
From step one my journey with RxPharmacist has been in my control, I was allowed to make my own project schedule and also make my MPJE guide exactly how I wanted. I was EXTREMELY nervous to sign on, I was concerned it would be too much to do with work, having a family, job hunting, and studying for the NAPLEX and MPJE, but I am so glad I bet on myself and the support RxPharmacist provided to take on this internship program. I have a completely unique addition to my CV, a new mentoring network, and an incalculable boost to my confidence.
I would highly recommend anyone who is eyeing this internship to apply! It is a highly competitive process, but well worth it.
-Ally B., 2021 RxPharmacist Graduate Intern
University of Minnesota College of Pharmacy, Class of 2021
The Compounding Conundrum of Personalized Medicine
It is no wonder personalized medicine has been taking a rise, after all, the one size fits all approach seen in manufactured medicine cannot work for everyone. For patients with unique healthcare needs, compounding can be incredibly useful but the catch is these medications do not actually go through a traditional approval process. Why is that important? It means these medications and products have not been reviewed, studied, and evaluated by a third party regulatory entity such as the Food and Drug Administration (FDA).
Compounding is defined as the process of “combining, mixing, or altering ingredients to create medications tailored to the needs of an individual patient”1. For example, a patient with allergies to certain ingredients in a medication (such as a preservative or dye) can receive a modified compounded form instead1. Another example is a patient who may require an alternate dosage form (such as a liquid as opposed to a tablet) which is especially prominent in pediatric or geriatric populations1. You can see the interactable module below which outlines common pharmaceutical ingredients used in compounding:
Access to compounding services are invaluable for some patients; however, vigilance is critically important in this particular field of practice. In the absence of FDA review and approval, guaranteeing the safety, efficacy and quality of these medications can be tricky… so tricky you might even call it a compounding conundrum. In 2012, a Massachusetts pharmacy caused more than 750 infections and more than 60 fatalities across 20 states due to fungal contamination2. This event would lead to the Drug Quality and Security Act (DQSA) to be passed that same year and officially enacted during the following year2. A prior blog post of ours outlined the need for REMS programs and why we can’t be hasty when it comes to drug safety, the same is particularly true in this case as patients can be placed in serious harms way when appropriate measures or precautions have not been taken in compounding.
The following links below assembled by the United States Pharmacopeial (USP) Convention are highly useful in better understanding appropraite standards for compounding and have been linked below for your convenience:
The FDA also provides a plethora of compounding guidance and resources found here as it is trying to gain a more involved approach given the recent deaths and news from a lack of quality assurance and sterility in compounded products causing patient harm. For example, there is a federal law that specifies a 5% limit on distribution for out of state drugs compounded by pharmacies and physicians under Section 503A of the FDCA. The FDA plans not to enforce this rule until after states sign and finalize the memorandum of understanding (MOU) as ultimately it is under the state jurisdiction and regulation to oversee compounding pharmacies.
Sincerely,
Jean Hanna
References:
Compounding and the FDA: Questions and Answers. U.S. Food and Drug Administration. https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers. Published 2018. Accessed May 6, 2021.
Compounding and the FDA: Questions and Answers. U.S. Food and Drug Administration. https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers. Published 2017. Accessed May 6, 2021.
Ansel H, Allen L. Pharmaceutical Dosage Forms And Drug Delivery Systems. 10th ed. Philadelphia, Pa: Lippincott-Williams & Wilkins; 2014.
Many years ago, I came across a tale of The Wheezing Wolf and the Three Little Pigs (you could call it a breathless spin on a timeless children’s classic). It is also a tale that manages to very creatively highlight a disease state which affects a large number of children worldwide – that’s right, asthma! It is estimated more than 22 million people (~6 million children) in the United States have some form of asthma, a chronic but reversible condition which causes inflammation and bronchoconstriction of our airways1.
Although there is no magic bullet or cure for people who suffer from asthma, we have a large variety of medications that allow for proper management which helps prevent long term airway remodeling, permanent lung damage, hospital stays and emergency room visits1. You might be wondering what causes people to acquire asthma… maybe it’s people spending a lot of time with wolves who huff and puff or maybe it just happens to be all the Hufflepuffs? Well, data is gathered meticulously to better highlight trends in asthma for this very reason. For example, one trend already identified makes clear that african american and hispanic children are generally more likely to experience mortality from asthma related causes1. Below you will find several interactable modules which outline the rise in asthma cases over the years but also the demographic aggregation of cases across the United States:
One theory that has gained traction over the years to explain the rising cases of asthma is called the hygiene hypothesis. This hypothesis suggests our post natal immune response is compromised by an ultra clean environment, causing a lack of exposure to infectious organisms and consequently leading to an “uneducated” immune system (which is more likely to predispose a child in developing conditions like asthma)3. The bacterial protein lipopolysaccharide (LPS) is an example of how our immune system can grow, learn and graduate school by “switching” on toll-like receptor 4 (TLR4), a characteristic shared by the respiratory syncytial virus (RSV) F protein commonly encountered by infants3. It is still up in the air whether RSV is helpful in the same way LPS is in regards to building a solid immune system, or whether it actually does more harm than good by potentially suppressing proliferation of T cells; however, it is an area of expanding research as we continue to ponder what effects clean houses could potentially have on the rising incidence of disorders such as asthma3. If you would like to learn more about the hygiene hypothesis and the potential implications as we navigate through the COVID-19 pandemic, this article (“The hygiene hypothesis, the COVID pandemic, and consequences for the human microbiome”) is a nice read.
As a whole, asthma attacks can vary in severity and in nature from one person to another; however, common triggers include tobacco smoke, dust mites, pollen, air pollution, mold, a man’s best friend, perfumes, harsh cleaners/disinfectants and even acid reflux2. It is important for patients who suffer from asthma to identify and avoid triggers. For example, encouraging tobacco cessation in households with smokers or using an air cleaner with a HEPA filter for people who may be allergic to their furry friends2. And lastly, if there is one thing we know from the hygiene hypothesis, it’s that people love to clean their homes. It is especially true now perhaps more than ever before and we may very well see an even steeper rate of asthma cases moving forward, even if just from COVID sequelae alone. Here is a CDC guide to properly cleaning and disinfecting homes that patients (especially those sensitive to harsh detergents or cleaners) may find useful; it’s even COVID approved.
Sincerely,
Jean Hanna
References:
Asthma Fact Sheet. (2019, May 22). Retrieved from https://www.fda.gov/consumers/minority-health-and-health-equity/asthma-fact-sheet
Common Asthma Triggers. (2020, August 21). Retrieved from https://www.cdc.gov/asthma/triggers.html
Asthma: The Hygiene Hypothesis. (2018, March 23). Retrieved from https://www.fda.gov/vaccines-blood-biologics/consumers-biologics/asthma-hygiene-hypothesis
Before my graduation in 2020, I was uncertain about my career and future with pharmacy being heavily saturated and the COVID-19 pandemic hit creating an ecomonic downturn. I first came across the summer internship at RxPharmacist because I recognized the opportunities that they offered including the flexibility of a remote work role, creating my own study guide, and achieving growth in medical technical writing and growing my professional network. Now as I complete the program, I am glad to share with you this incredible experience at RxPharmacist.
My first project was to edit the CPJE guide, which aided me passing the exam on my first attempt. Besides providing feedback on my work performance, my inspiring mentor spent time discussing with me about entrepreneurship, marketing, and my career goal. There was a heavy emphasis on strategy to approach achieving my goals of attaining my dream fellowship program. For example, knowing my interest in the pharmaceutical industry, she introduced me to experts in the field and helped me on my CV, letter of intent, and practicing with mock interviews. Thanks to her unwavering support, I got accepted into my top choice fellowship program where I would practice as a clinical development fellow in oncology at Rutgers (2021-2023). Although I was already working as a full-time pharmacist, this remote job was so flexible that it allowed me to work on my own schedule. Needless to say, beyond a job, not only the internship offered a unique opportunity to expand my networks and writing skills, but it also was a good transition for me from a graduate student to a pharmacist. I’m incredibly thankful of being able to get into my top fellowship program with the unwavering support of RxPharmacist and also was able to gain the FDA ORISE fellowship as a backup opportunity should I not be able to get my top choice through their help.
Therefore, I highly recommend this internship to anyone who seeks for professional networks and experience in medical and scientific communications. The preceptors and team are highly supportive. If your willing to work hard, learn new skills, and try something new, this might be a wonderful opportunity for you.
Thi N., 2020-2021 RxPharmacist Graduate Intern
UC San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, Class of 2020
The Fault in Our Stars is a novel written by John Green. Since its release in both print and film, the moving story has managed to strangle many hearts around the world as it explores many colorful yet melancholic themes of life, cancer being among them. One example is a clever nod to Shakespeare’s Julius Caesar, specifically the following line by Caddius: “The fault, dear Brutus, is not in our stars, / But in ourselves, that we are underlings” 6. Of all the literary works I’ve read and enjoyed over the years, this line has been especially memorable. Caddius implies fate (or stars for that matter) is a negligible force, for it’s a person’s own fault alone if their life falls short of their expectations. By titling his book “The Fault in Our Stars” it is clear Green disagrees, at least as it pertains to cancer and our dear protagonists in the novel.
Although cancer can certainly be acquired through environmental means such as smoking or radiation, it can also be genetic. In fact, if we want to get a little more technical, for a select group of people their undoing could specifically be a fault in their epidermal growth factor receptor or EGFR (HER1/ErbB1) gene2. EGFR positive lung cancer is most common in people who have never/rarely smoked, have adenocarcinoma, women, young adults and people of asian or east asain heritage2. Additionally, adenocarcinoma is a subtype of non-small cell lung cancer (NSCLC) which causes nearly 80-85% of all lung cancers4. Risk of acquiring adenocarcinoma is increased for patients who smoke, inhale second hand smoke, and are exposed to radon gas, asbestos or other cancer-causing agents in their daily lives4.
Generic Naming Formula: Name = prefix + substem(s) + stem
Image adapted from: RxPharmacist CPJE Study Guide 2020
If we are dealing with an EGFR positive case of lung cancer and wish to decide on a medication, it makes sense we would attempt targeted therapy as opposed to standard chemotherapy in order to directly inhibit the EGFR receptor. Therefore, NSCLC EGFR+ patients can typically be administered EGFR inhibitors (as outlined below). I have included some other potential mutations and their therapies as a bonus below. Note they all end in -nib, as they are all tyrosine kinase inhibitors (TKI), the bolded drugs are preferred. As far as terminology, medications ending in ‘-mab’ denote monoclonal antibodies which are biologic type medications as they are usually therapeutic proteins and large structures chemically. Medications ending in ‘-nib’ are usually small molecules, think of this as a car versus an airplane which are ‘-mabs’ for size.
You should anticipate a rise in biosimilar oncology medications on the market. Overall, the Food and Drug Administration (FDA) has approved 29 biosimilar medications so far, and almost all of them have a role to play in oncology therapeutics. If you want a much deeper dive into oncology and many more disease state topics, check out our CPJE Study Guide. Additionally, here are some useful resources on cancer you can also reference:
“What Causes Cancer?” American Cancer Society, www.cancer.org/cancer/cancer-causes.html.
“EGFR Mutation and Lung Cancer: What Is It and How Is It Treated?” Lung Cancer Foundation of America, 18 Oct. 2019, lcfamerica.org/lung-cancer-info/types-lung-cancer/egfr-mutation/.
“What Is Lung Cancer?: Types of Lung Cancer.” American Cancer Society, www.cancer.org/cancer/lung-cancer/about/what-is.html.
Publishing, Harvard Health. “Adenocarcinoma of the Lung.” Harvard Health, www.health.harvard.edu/a_to_z/adenocarcinoma-of-the-lung.
“Non-Small Cell Lung Cancer Targeted Drug Therapy: Lung Cancer Drugs.” American Cancer Society, www.cancer.org/cancer/lung-cancer/treating-non-small-cell/targeted-therapies.html.
Shakespeare, W., Mowat, B. A., & Werstine, P. (2005). The tragedy of Julius Caesar. New York: Washington Square Press.
It is estimated nearly 34.2 million people in the United States have some form of diabetes (⅕ of which are entirely unaware), and in the last 20 years the number of diagnosed adults has more than doubled in size1. The significance of this disease state is paramount from a public health perspective, especially as diabetes has been identified as the number one cause of kidney failure, lower limb amputations and microvascular complications1. You can think of diabetes as a metabolic disease which is generally broken down into four categories: type one diabetes, type two diabetes, gestational diabetes (onset during pregnancy) and prediabetes (elevated blood glucose levels that are yet to be considered entirely diagnostic of active disease)1.
The following video (“Diabetes and the body”) is an excellent visual resource for understanding diabetes and its associated consequences on the human body. Both type one and type two diabetes cause an accumulation of glucose in the bloodstream; however, it is the etiology that differentiates them. Type 1 diabetics essentially experience autoimmune destruction of their pancreatic beta cells which diminishes endogenous insulin production (usually diagnosed in younger people and makes up 5-10% of diabetics)1. In comparison, type two diabetics can produce insulin just fine but their body is unresponsive due to built up insulin resistance over time (usually diagnosed in adults and makes up 90-95% of diabetics)1.
The tricky thing about insulin is it must be injected because it is easily broken down and digested in oral form2. All patients with type one diabetes will be dependent on exogenous insulin for survival, and some type two diabetics may also require insulin for adequate control. There is a highly interesting concern in type two diabetes management surrounding a delay in insulin initiation, typically dubbed “clinical inertia”. You can read more about in the following literature review (“Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review”).
Insulins can be deadly when used inappropriately. It is important to understand and be familiar with the onset, peak and duration of insulins (as seen in the figure above) so an appropriate personalized regimen or adjustment can be made for each patient’s needs and goals. Generally, rapid and short acting insulins are intended for bolus purposes whereas intermediate and long acting insulins are intended for basal purposes. We can categorize and identify insulins in the following five categories below (note that Afrezza is inhaled as opposed to injected and can be given at the start of each meal (which may be a great option if a patient is looking for non-injectable options):
I hope this dive into insulins and their place in diabetes management has been helpful for you and your studies. As an aside, one important public health issue as it relates to insulins is actually affordability. You see, supposedly 1 in 4 diabetic patients can’t afford their insulin altogether4. The issue is complex and significant enough to have it’s own dedicated gofundme page as for many patients insulins are a non-negotiable lifeline. You can read more about the black market dedicated to the insulin trade here, but remember there are resources for patients who need them should you ever directly encounter this issue in the community. Some patients may also obtain over the counter insulin from Walmart’s ReliOn insulin program.
Sincerely,
Jean Hanna
References:
What is diabetes? (2020, June 11). Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html
Insulin Basics. (n.d.). Retrieved from https://www.diabetes.org/healthy-living/medication-treatments/insulin-other-injectables/insulin-basics
Insulin and diabetes. (n.d.). Retrieved from https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/treating-your-diabetes/insulin
Teare, K. (2018, December 03). One in four patients say they’ve skimped on insulin because of high cost. Retrieved from https://news.yale.edu/2018/12/03/one-four-patients-say-theyve-skimped-insulin-because-high-cost
