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Pharmacy Residency Rotation Opportunities

Residents are exposed to a wide variety of areas and have different options to customize their residency year. Billings Clinic aims to make its residents well-rounded leaders in pharmacy practice.

Core Patient Care Rotations/Experiences (Required)

Cardiology: 5 weeks

  • Location: Cardiovascular Unit (CVU), which is a 29-bed inpatient unit with an average patient length of stay of approximately 36 hours. The CVU staff is primarily responsible for the care and monitoring of cardiac, critical care step-down, and stroke patients admitted to the hospital. Pharmacy services on CVU are provided by a decentralized pharmacist from 0630 – 2000, Monday – Friday.
  • Residents round with cardiology providers in the inpatient setting, observe various cardiac-related procedures (e.g., catheterization, cardioversion) and surgeries, assist the CVU pharmacist with clinical duties, educate patients on new medications (e.g., cardiac, anticoagulation), and much more. Depending upon interests, residents can also spend a couple days with the ambulatory care cardiology clinical pharmacist.

Critical Care: 5 weeks

  • Location: Intensive Care Unit (ICU), which is a 24-bed mixed medical and surgical inpatient critical care unit. Pharmacy services in the ICU are provided by one to two decentralized pharmacists, typically from 0630 – 1700.
  • Residents round with the ICU pharmacist and intensivist physician throughout the day, actively contribute to interdisciplinary ICU rounds, assist the ICU pharmacist with clinical duties, and respond with the ICU pharmacist to cardiopulmonary resuscitation (CPR), stroke, and trauma events as available.

      Infectious Diseases: 5 weeks

      • Location: Infectious Diseases (ID) is centered around the ID and Antimicrobial Stewardship (AMS) services. The ID pharmacist is available from 0700 – 1530 on weekdays. The pharmacist’s primary responsibilities include rounding with the ID physicians, participation in AMS rounds and other activities, and assisting the adult and pediatric pulmonologists with management of cystic fibrosis patients.
      • Residents are involved in AMS activities (e.g., rounds, antimicrobial restriction, patient/culture reviews, projects), gain exposure to microbiology lab and infection control, and participate in the antimicrobial management of cystic fibrosis patients.

      Internal Medicine: 5 weeks

      • Location: Internal Medicine is centered around the Internal Medicine Residency (IMR) interdisciplinary rounding service. The IMR pharmacist is available from 0700 – 1530 on weekdays. The pharmacist’s primary responsibilities include rounding with the IMR teams as well as providing back-up coverage for the inpatient medical and surgical decentralized pharmacists.
      • Residents focus on rounding with the IMR physicians and interdisciplinary team. The first 1 – 2 weeks are spent working side-by-side with the IMR pharmacist learning how to effectively function as a pharmacist within the team. The remainder of the rotation is spent rounding independently with an IMR inpatient team, while the IMR pharmacist rounds with another team.

      Medical Emergencies - Longitudinal (11 months)

      • Location: Medical Emergencies is a continuation and augmentation of the concepts introduced in the advanced cardiovascular life support (ACLS) certification course. The experience focuses on the pharmacist’s role in responding to cardiopulmonary resuscitation (CPR), stroke, and trauma events. At least one inpatient pharmacist responds to all CPRs, strokes (level 1), and traumas (level 1) around-the-clock.
      • Residents become ACLS certified and may have the opportunity to become pediatric advanced life support (PALS) certified, depending on their interests and class availability. Residents respond to codes with another pharmacist, participate in Simulation Lab mock codes, and facilitate a CPR Skills Lab competency session for the inpatient pharmacists. Residents carry a pager from 0700 – 1700 during weeks when they are on-call and respond to medical emergencies during these times. Residents are on-call for approximately 10 weeks of the year (ICU and cardiology rotations typically).

      Selective Patient Care Rotations (Options)

      Ambulatory Care: 5 weeks

      • Location: Ambulatory Care is centered within the Internal Medicine/Family Medicine department. The Medication Therapy Services (MTS) clinic is a pharmacist-directed, ambulatory care practice that involves protocol-driven, collaborative drug therapy management of patients with diabetes mellitus, hyperlipidemia, hypertension, asthma, COPD, and tobacco dependence; providing services for bariatric patients; conducting pharmacogenomic consultations; and comprehensive medication management. Patients are scheduled between the hours of 0800 – 1630.
      • Residents become proficient in providing a complete pharmacotherapy work up including assessment of drug therapy problems, written recommendations, and determining appropriate monitoring and follow-up. Residents also provide evidence-based disease state-specific drug therapy management that includes initiation, titration, and discontinuation of medications; obtaining vital signs; laboratory monitoring; and educating patients regarding lifestyle modifications for their chronic disease states. Depending upon interests, residents may also spend time with the ambulatory care clinical pharmacists in cardiology, oral oncology, rheumatology/neurology, and pediatric specialty.

        Emergency Medicine: 5 weeks

        • Location: Emergency Medicine is centered in the Emergency Department (ED), which consists of 4 pods. Pharmacy services in the ED are provided by one decentralized pharmacist from 0930 – 2000 and a second decentralized pharmacist from 1430 – 0100.
        • Residents assist the ED pharmacist(s) with their clinical responsibilities, including order processing; pharmacist-driven protocols; attending CPR, stroke, and trauma calls; responding to myocardial infarction response team activations; assisting with procedural sedations and intubations; and antimicrobial stewardship (e.g., culture monitoring/recommendations). Additionally, residents provide staff and patient education, assist with medication history-taking and medication reconciliation, and answer drug information questions.

        Medication Reconciliation/Transitions of Care: 5 weeks

        • Location: Medication Reconciliation/Transitions of Care (MR/TOC) is centered around the MR/TOC pharmacy service, which focuses on medication management during hospital transitions of care. The MR/TOC pharmacists are available 0730 – 1930 on weekdays and 0800 – 1830 on weekends. The MR-MED pharmacist’s daily activities include reconciling medication lists for patients transferring to a skilled nursing facility, obtaining accurate medication histories for complicated medical patients, interacting with hospitalists, and reconciling medications. The MR-SURG pharmacist’s daily activities include reviewing, organizing, and prioritizing MR-SURG consults; interacting with admission-discharge-transfer (ADT) nurses, surgeons, and their midlevel practitioners; obtaining accurate medication histories; and reconciling medications. The MR-F pharmacists’ assists with the workload of the MR-MED and MR-SURG pharmacists and helps prioritize tasks for the team.
        • Residents enhance their patient interviewing and counseling skills as well as increase their therapeutic medication management knowledge and skills. Residents review patients’ home medications, inpatient orders, vitals, labs, and any other pertinent information to accurately and safely reconcile medications at hospital admission and discharge using the established protocols for the MR/TOC service.


        • Location: Neonatology is centered on the Family Birth Center (FBC), which is a multi-functional unit consisting of labor & delivery as well as the Neonatal Intensive Care Unit (NICU). Pharmacy services for the NICU are provided by one decentralized pharmacist from 0700 – 1530 on weekdays. Clinical responsibilities for FBC patients are the responsibility of the NICU/FBC pharmacist, while order processing for FBC is typically completed by the main inpatient pharmacists.
        • Residents participate in interdisciplinary rounds and other clinical activities with the FBC pharmacist. Residents become familiar with neonatal medications, nutrition, and responding to emergent situations (e.g., CPRs) in these patients. They also help care for pregnant patients and address their unique pharmacotherapy needs.

          Oncology: 5 weeks

          • Location: Oncology (ONC) is centered in the adult Infusion Center but also provides exposure to other oncology services, including inpatient adult oncology, ambulatory care oral oncology, as well as outpatient and inpatient pediatric oncology. The Cancer Center provides outpatient treatment facilities for radiation and a 26-chair adult Infusion Center (IC). Pharmacy services in the IC are provided by two oncology pharmacists from 0730 – 1800, Monday through Friday. Adult oncology services are also provided in the Inpatient Cancer Care (ICC) unit by the ONC pharmacist on weekdays from 0700 – 1530. Pediatric oncology services are provided by the ambulatory pediatric clinical pharmacist specialist.
          • Residents gain experience in both the inpatient and outpatient adult and pediatric oncology settings; attend numerous interdisciplinary activities, including tumor boards, supportive care team, and cancer research meetings; spend time with oncologists seeing patients in clinic and the hospital; and observe surgery (when available). Residents also help ensure appropriate dispensing of pre-medications, chemotherapy, and immunotherapy; monitor patients’ labs, vital signs, and functional status to ensure treatment is safe; conduct anti-emetic consultations; and provide drug information to providers, nurses, and other members of the cancer care team.

          Pain Management

          • Location: Pain Management is centered around the Acute Pain Service. The consult-based service is staffed by a lead clinical pharmacist from 0800 – 1630 Monday on weekdays and a nurse practitioner from 0700 – 1700 every day. The team evaluates and assists in the care of patients needing acute pain management.
          • Residents will assist the pain team with interviewing patients, assessing pain management prior to hospitalization, evaluating and recommending pain management strategies during the acute visit, and creating patient-specific plans for pain management at discharge. Residents may also be involved with process improvement projects and opioid stewardship.

          Psychiatry: 5 weeks

          • Location: Psychiatry (Psych) is centered in the Psych Center. The Psychiatric Adult Treatment Unit provides inpatient services for adults, including geriatric care for adults who are transitioning between hospital psychiatric inpatient care and nursing home level care. Adolescent (ages 6 – 17 years) services are provided in the Psychiatric Youth Treatment Unit. The Youth Partial Hospitalization Program provides outpatient treatment and education for children and adolescent ages 7 – 17 years who can benefit from active treatment in a therapeutic setting. The Psychiatric Stabilization Unit is an observation unit that cares for patients who require acute mental illness stabilization but do not need to be admitted to the Psych Center. Pharmacy services in the Psych Center are provided by one decentralized pharmacist from 0800 – 1630 (weekdays).
          • Residents round with the Psych pharmacist and psychiatric hospitalists throughout the day. They also assist with the Psych pharmacist’s clinical duties (e.g., order processing, pharmacist-driven protocols, multidisciplinary rounds, patient interviews and counseling) and participate in Project ECHO sessions.

          Other Experiences (Required)

          Orientation: 4 - 5 weeks

          • Orientation is one of the first learning experiences for all PGY1 pharmacy residents. It is started simultaneously with the Drug Information – Concentrated rotation and consists of regular meetings between the Residency Program Director and residents. Orientation focuses on educating residents on policies, procedures, expectations, schedules, and project requirements; determining each resident’s individual professional experiences to-date and developing goals and a customized development plan for residency; discussing PharmAcademic™ (electronic evaluation system); and familiarizing the residents with Billings Clinic and the Pharmacy Department.

          Pharmacy Practice: 8 weeks

          • Pharmacy Practice is centered in the various inpatient pharmacy areas with approximately half of the time spent in the Main Inpatient Pharmacy. Pharmacist coverage in the Main Inpatient Pharmacy is provided by 2 – 3 pharmacists seven days-a-week. The Early Screener (ES) pharmacist works from 0700 – 1730 every day, while the Late Screener (LS) pharmacist is scheduled from 1030 – 2200 each day. The Lead-Main (LD‑MN) pharmacist typically works from 0800 – 1630 Monday – Friday. The morning portion of the LD-MN shift performs a staffing role, while the afternoon portion is typically dedicated to projects/meetings. Night shift coverage for the Pharmacy is provided by one pharmacist during the hours of 2100 – 0730 every day.
          • Pharmacy Practice is the second learning experience for all PGY1 pharmacy residents and start after the Orientation and the Drug Information – Concentrated rotations. Residents become confident in the use of pharmacy information systems, evaluation of prescriber orders, completing pharmacist-driven protocols, and the utilization of the integrated dispensing system, which consists of a combination of a 24-hour patient-specific medication fill, carousel system, automated dispensing machines, and centralized sterile intravenous admixture service. Residents develop sufficient skills in dispensing, drug distribution, and workflow management and learn relevant policies and procedures, so they are able to function appropriately within the medication-use system during their longitudinal staffing shifts.

          Drug Information - Longitudinal (12 months)

          • Drug Information (DI) has two components: a 4 – 5 -week concentrated rotation followed by a longitudinal component throughout the remainder of the residency year.
          • The DI Concentrated rotation runs concurrently with the Orientation rotation and is stretched throughout the first 4 – 5 weeks of residency. It consists of weekly meetings between the preceptor, Residency Program Director, and residents. The DI Concentrated rotation focuses on the skills necessary for formulating written DI responses. Residents also learn to lead professional journal article discussions and gain experience presenting on different drug information topics.
          • The DI Longitudinal experience is a continuation and augmentation of concepts introduced in the DI Concentrated rotation. Residents advance their ability to critically evaluate literature and its application to practice; provide timely and accurate drug information responses to providers, nurses, other interested healthcare professionals, and patients; lead professional discussions on journal articles; and have topic discussions on literature evaluation and biostatistics in an effort to prepare to successfully pass the Board of Pharmaceutical Specialties’ Pharmacotherapy examination following the completion of the residency year.

          Pharmacy Academia - Longitudinal (12 months)

          • Pharmacy Academia is a multi-faceted experience aimed to prepare residents to effectively educate others. Residents are involved in a variety of teaching activities throughout their year including didactic lectures; literature presentations; in-services; patient case presentations; topic discussions; and other types of education for patients, providers, and other healthcare professionals. Residents present lectures at Pharmacy Grand Rounds (twice), which is a community-wide continuing education program. Similarly, residents present once each at Nursing Grand Rounds and Physician Grand Rounds (internal continuing education programs) and are guest lecturers for the Rocky Mountain College Master of Physician Assistant Studies program. Additionally, residents gain experience with precepting and mentoring student pharmacists during their experiential rotations at Billings Clinic. Residents serve as resources for the student pharmacists and provide guidance, if needed, with presentations, projects, drug information responses, medication use evaluations, and much more. During times in the year, residents may be assigned as the primary preceptor for student pharmacists. Residents also have the opportunity to obtain the ASHP Teaching Certificate for Pharmacists.

          Pharmacy Administration - Longitudinal (9-10 months)

          • Pharmacy Administration focuses on developing residents as leaders, improving their project management skills, and providing them with exposure to various pharmacist administrative roles as well as instituting departmental and organizational changes. Residents work closely with the preceptor and other members of the Pharmacy Leadership team to implement positive changes in the medication-use process through committee meeting attendance; observation of relevant activities; drug monographs/formulary reviews; and developing/updating clinically-oriented policies, protocols, guidelines, pathways, or electronic order sets. They gain exposure to different aspects of pharmacy operations and the medication-use system, including clinical programs, budgeting, staffing, evaluations, formulary and inventory management, renovations, regulatory compliance, and much more.

          Research/Project - Longitudinal (12 months)

          • Research focuses on helping residents develop and complete at least one major project (typically research) on some element of pharmacy practice, utilizing the support and guidance of experienced project advisors. Residents are provided direction through each step of their projects, including the Institutional Review Board approval process and completion of project manuscripts. The primary purpose of the learning experience is to provide residents with experience in development, implementation, analysis, and presentation of a major project. Residents gain skills in project management and team leadership. Projects should be feasible, interesting, novel, ethical, and relevant. Projects may be each resident’s own choice or selected from a list of potential projects compiled by the program. All research projects have a pharmacist preceptor as the primary co-investigator but often have 3 – 4 members composing the research team. To help residents prepare, they participate in discussions on research-related topics with the Residency Program Director (RPD) during their Orientation rotation. Residents present their initial project background and methodology at ASHP Midyear Clinical Meeting in December (poster format) and formally present their results at the Montana Pharmacy Association Spring Seminar in April and Mountain States Conference in May. Prior to the end of the residency program, residents are required to submit a final project manuscript of publishable form to their project teams and the RPD.

          Pre- and Post-Intervention - Longitudinal (3-6 months)

          • The Pre- and Post-Intervention Project is a required longitudinal learning experience that lasts approximately 3 – 6 months. During the year, residents develop and complete at least one project the includes implementing a change (e.g., protocol, process improvement) and assessing data pre- and post-implementation of the change. This is a separate project from the residents’ research/major project and is typically smaller in scope. It also differs from the residents’ medication use evaluations (MUEs). The primary purpose of the Pre- and Post-Intervention Project learning experience is to provide residents with the skills necessary to identify opportunities for improvement within the medication-use system and subsequently design, implement, and assess changes therein. Residents gain skills in project management and team leadership. Usually, residents’ Pre- and Post-Intervention projects are focused within the Pharmacy Department, but residents may work on interdepartmental projects. Projects should be feasible, relevant, and based on best-practice standards. All projects have a primary pharmacist preceptor but typically include a team of 2 – 3 people.

          Staffing: Longitudinal (10 months)

          • Staffing is a continuation and augmentation of concepts introduced in the Pharmacy Practice rotation. The focus of the Staffing longitudinal learning experience is on the provision of hospital pharmacy services as they relate to other healthcare practitioners. Specifically, the experience incorporates order processing, medication dispensing, workflow management, as well as clinical pharmacy services. Since a primary goal of the learning experience is to develop the residents’ abilities to practice independently and function within the medication-use system at Billings Clinic, residents staff clinical pharmacist shifts on a rotating basis every 2 – 4 weekends (averages to every 3rd weekend). Approximately half of residents’ staffing shifts are completed in the Main Inpatient Pharmacy with the remainder as decentralized float shifts. Residents also staff one holiday (Labor Day, New Year’s Day, Easter Day, or Memorial Day). However, in order to maximize learning and minimize disruption in clinical rotations, residents are not utilized to cover shifts for co-workers who have “called in-sick”. Residents are allotted one day off (typically Mondays or Fridays) for working their weekends.

          Educational Goals and Objectives

          Billings Clinic has selected the following educational competency areas:

          • R1: Patient Care
          • R2: Advancing Practice and Improving Patient Care
          • R3: Leadership and Management
          • R4: Teaching, Education, and Dissemination of Knowledge
          • E5: Management of Medical Emergencies

          Competency areas R1 through R4 are required for all ASHP-accredited PGY1 pharmacy residency programs. Billings Clinic has opted to also include an additional competency area (E5) to augment residents’ experience. For more information about the ASHP PGY1 pharmacy residency program educational competency areas or the specific goals and objectives under each competency area, please visit the ASHP website.