Interview with Dr. Jessica Nesheim. Jessica Nesheim is an Emergency Medicine Clinical Pharmacy Specialist at Mercy Medical Center in Des Moines. She graduated from Drake University with PharmD in 2009 and completed a PGY1 Pharmacy Practice residency at Mercy Medical Center, Des Moines in 2010. She is a Board Certified Pharmacotherapy Specialist, the primary preceptor for PGY1 residents on required EM learning experience and a preceptor and Program director for EM PGY2 residency program at Mercy, now in its second year.
Everyone’s leadership road is a little different; tell us what you are doing now and how you got there.
Right now I am the Emergency Medicine Clinical Pharmacy Specialist at Mercy Medical Center in Des Moines. That entails a lot of different elements. I do quite a bit of staffing still in the emergency department, but on top of that I have several clinical responsibilities for developing clinical practice within the emergency medicine realm. That includes order sets and protocol development, interdisciplinary committee involvement along with MUEs, collaborate practice agreement development and many other aspects. Also, as you mentioned, I am the Program Director for our new Emergency Medicine PGY2 residency program. That involves quite a bit of different things.
I got here in a pretty direct route, I would say. I got my first introduction to Emergency Medicine Pharmacy as a fourth year pharmacy student after attending the ASHP MidYear meeting. I had attended a round table discussion that I happened to wander through. I sat down at the table where Daniel Hays was speaking about Emergency Medicine Pharmacy. That was really my first introduction. I had never heard of Emergency Medicine Pharmacy before or had any idea what that job entailed. Moving forward, I knew that I wanted to complete a pharmacy residency. I looked for programs that offered some kind of experience in the emergency room. I didn’t know if that was where I necessarily wanted to practice, but I wanted some additional exposure. That kind of set my trajectory on the program searches. I did interviews, but unfortunately I did not match through the residency program match. I do think it worked out for the best because I did end up as a resident at Mercy Medical Center in Des Moines. They didn’t currently have any experiences in the emergency department, but during my residency year we opened our sister hospital her in Des Moines on the west side of town, which is Mercy West Lakes. The new clinical coordinator at site was tasked with exploring and trying to pilot a program within the emergency department. As a resident, I was given the opportunity to help assist with that. Through our involvement and data collection, we were able to gain approval for two FTE’s, so two full-time positions in the emergency department on our main campus. I was offered one of those positions, so I decided to forego PGY2 training and jumped head-first into the ED. I have been doing it and loving it ever since.
For someone thinking about a specialized PGY2, how do they keep both an eye on the specialty they are working towards and still staying true to the foundational nature of a PGY1?
I think sometimes first year residents can get lost, or maybe lose sight of what the ultimate goal of the PGY1 residency is and that is really to build a strong foundation in all of those core areas. You are going to have to recall that knowledge no matter what specialty you are in. There are some ways to leverage that PGY1 experience if you know what you want to go into or know you want to pursue that specialty. I think trying to have your research project focus in on that area you want to specialize in. That always speaks volumes when you go to interview at programs that they know that you have already done some research in that area. It also shows your level of commitment to that specialty. I think you can maximize your elective opportunities as well, not just to repeat that area as a learning experience, but maybe to find areas that would complement that. For example, for emergency medicine I try to encourage our PGY1’s, if they want to pursue emergency medicine, to consider something in pain management or psych because those are huge elements of the emergency department. I think that increases your comfort in those subspecialty areas.
The other thing along with that is to keep open. You never really know, you might go into PGY1 or find something you have a major interest in. You never know when the tides may turn and you find something else that you never considered before.
Many of our listeners are going to MidYear in December, did you focus specifically on the PGY1 at that meeting, or were you looking at both PGY1s and PGY2s?
I really just focused on the PGY1s but I have the PGY2s in the back of my mind. No necessarily looking at those programs, but using that as an indicator of a strong program in that area. So if a PGY1 program that you are interested in also has a PGY2 in that area of interest or offers a required learning experience in that area, you can be pretty sure it is going to have some strong components in that field. Some programs have PGY2s that may offer early commitment, but that is not all programs and it is definitely ever a guarantee. So I would never want to set all of my expectations for the PGY1 that you are going to get the PGY2 and stay with that program, but you can weigh that into the considerations for the programs you are interested in.
Do you have an early commitment option for your program?
We do. We created a policy for both of our PGY2 programs, Emergency Medicine and Infectious Disease. So that is something that would be a potential here.
What are one or two things we don’t know about Emergency Medicine pharmacy practice that would help us understand what it’s like on a day-to-day basis?
It is kind of to be expected in the emergency department, but it is totally unpredictable to know what your day is going to be like. No two days are ever the same, which I particularly enjoy. It is very hands-on and I would say that is true for every Emergency Medicine program. There is definitely a variability in our area of practice right now, because it is so new. We are practicing at the bedside. We are a member of the team as equals of our respiratory therapists, our nurses, and our technicians. We are all at the bedside together taking the best care of the patient that we can. Also, there are things that I have seen and smelled in the ED that I never imagined getting exposure to going through pharmacy school. It is a different world, I would say, but it is definitely exciting and very gratifying working side-by-side with the physicians.
What was one of the most challenging days you had as a pharmacy resident? Can you tell us that story?
My most challenging day would have been immediately following residency. I decided to forgo PGY2 training because we were able to start up a practice of our own and set the course for how we wanted our practice to look like. I wrapped up my PGY1 training, took a week of vacation, and then I jumped head-first working 7-on-7-off. So I worked 7 days stretch. During that first 7-day stretch I saw and was involved in so many more things than I had in my entire PGY1 experience combined. I had spent some time within the emergency department in that training, but it was at a smaller hospital with less acuity. So being thrust into a trauma center with CPRs, resuscitations, and the nurses at that time didn’t really know what to expect from us. We were really trying to show and prove ourselves that we were a member of the team. That first Saturday night with the number of traumas that we saw and the resuscitations, I felt like fish-out of water. I was definitely in over my head. That first 6 months to a year was an extremely steep learning curve even after completing a residency already.
As an Emergency Medicine Pharmacist do you mostly work evenings and nights or is it 24/7?
We are not yet 24/7. That is definitely a goal of ours. We have expanded hours and there are some day shifts. When we started out, we were primarily evening hours trying to cover the prime times of our emergency department.
What made you decide to create an Emergency Medicine PGY2 residency program? How did you do it?
There is definitely a lot of paperwork. When I first went out seeking approval for starting out our residency program getting a buy-in from our administration was a huge element. So I wrote a business proposal showing the value of having a PGY2 in the area. I did attend the ASHP Residency Program Design and Contact workshop, which I felt was a huge advantage. It really walks you through the whole process of developing a residency program. The leaders of the workshop were accreditors, they were the people going into the site visit. They gave me an inside look of what they were going to be looking for when they were coming for their accreditation visit. They gave you some of those tips and tricks on making the best program possible. That was a lot of it and going through and developing structure. There were lots of conversation with the other preceptors that were going to be in the emergency department and with the resident to develop unique experiences and set that framework. I reached out to several other programs as well trying to get ideas for what other people have had success with. ASHP website does a really good job walking you through the accreditation process.
What is a day like for a resident in your program?
They have a set of required experiences similar to a PGY1. We meet at the beginning of the year and make their customized residency development plan. We figure out what their goals are for their residency year. Where they want to end up when they are finished and try to really set them up for success for their residency year. They work through their different learning experiences trying to check of those goals and objectives that we set out and the goals that are set out by ASHP for an Emergency Medicine resident. They have time to work on topic discussions, journal club, case presentations, lead education within the emergency department for our nurses and physicians, and work on their research project. There are a lot of different elements to fit in there, but I think it is working pretty well.
Often getting a residency is more about the right fit than the applicant with the most impressive CV? What are some characteristics of a student that would be a good fit for an emergency medicine residency?
I would say the biggest one is self-motivated, eager to learn, being willing to be pushed outside their comfort zone. I would say that holds true about any residency program to be willing to put it all out there. Dive in and be willing to immerse yourself. Everything that you are going to encounter is a potential learning opportunity, so really just embrace it as that. Don’t take anything for granted because that year will be done before you realize it.
There are clearly stressors in your work, how do you separate work and home life?
My strategy that I try to apply and adhere to is to leave work at work. Even if that means to stay an extra half hour late to tie up some loose ends or wrap up a project. I feel that I am able to set it down then at the end of the day.
What are you most excited about today?
What excites me about this area of pharmacy practice is that it is still new. Emergency Medicine pharmacy is still evolving and there is no one job description that fits everybody. Knowing that we can continue to advance practice and really set the stage for what the future Emergency Medicine Pharmacists will be doing is really exciting because there are really no two practices that are alike.
Anything else you would like to share?
I would like to put out there that it is a known fact that there are not enough programs to go around, which is unfortunate. The number of programs is increasing every year, but still the number of applicants that are highly qualify that don’t get residencies is kind of frightening I think for students that want to pursue this. So I wanted to say even if you don’t get a residency, it is not the end of the road. Just don’t give up on your goals and it might take a different route to get there than you originally thought. Look for those mentors and reach out to people as resources. If you really want to pursue certain objectives or a career path, keep at it. I think it can happen.
What is your best daily ritual to keep your work on track?
I still use lists on a daily bases whether it is the emergency department were I jot down what I was working on before I was called into a trauma. Then I can come back and finish up what I was working on, return that phone call etc. With my clinical obligations too, trying to keep track of what is going on and prioritize based on deadlines, what is most important to me, what I am trying to get done and how long it will take. I am terrible at estimating how long something will take so I usually take the original estimate and double it.
What inspires you?
I would say it is the staff and clinicians that I work with every day. We have a ton of really bright and motivated physicians, nurses and respiratory therapists. Getting to see the work that they do. I have always like the quote that “if you are the smartest person in the room, you are in the wrong room”. So I just like that I get to go and be around these other really smart and motivated people that are trying to advance practice. I get to learn something new every day still.