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“Adventure is a path. Real adventure – self-determined, self-motivated, often risky – forces you to have firsthand encounters with the world. The world the way it is, not the way you imagine it. Your body will collide with the earth and you will bear witness. In this way you will be compelled to grapple with the limitless kindness and bottomless cruelty of humankind – and perhaps realize that you yourself are capable of both. This will change you. Nothing will ever again be black-and-white.” – Mark Jenkins

Pharmacy students are given so many opportunities throughout school. Whether it is a unique elective, research with a fascinating professor, or in my case, a unique APPE rotation, we have fantastic experiences that help shape us into the pharmacists we hope to become. I recently returned from a 2-month APPE experience in Trujillo, Perú. I want to share a few of my key experiences with other members with the hope that you can better understand the pharmacy experience in another country. My experience is only reflective of my hospital, Hospital Belén de Trujillo, and may be different from other health systems within the country.

Pharmacy at Belén

Hospital Belén is a state hospital. As such, the majority of patients had either SIS (state insurance, similar to Medicaid) or did not have any insurance. Because of this, the hospital has extremely limited funds for services and staff.

The pharmacist’s role within the health system is primarily dispensing. My hospital had a decentralized model of pharmacy. It utilized a centralized facility, “almacén” or storage, which controlled central stock and distributed medications and supplies to the other pharmacy units throughout the hospital. The almacén is run by two pharmacists and 2-3 pharmacy technicians.

The decentralized units include:

Emergencia- This unit serves as a pharmacy for patients leaving the ED with prescriptions needing to be filled. It is usually staffed by 1-2 pharmacists.

Consulta Externa - This unit serves as a pharmacy for inpatients. Although the majority of medications are covered by SIS, some items are not. The patient or patient’s representative had to purchase these items before administration. Should they decide not to purchase them, they would not receive them during their stay. This rule is not completely black and white. As an example, there was a newborn with an extreme case of hydrocephalus whose parent’s visits were infrequent. The physician authorized the continuance of his medications even though the family had not paid for them. This unit is usually staffed by 2-3 pharmacists.

Pharmacotécnica - This unit’s primary responsibility is compounding. Due to the higher cost of pediatric medications, this unit focuses on creating pediatric/neonatal doses from adult products. A prescription is given from a physician for a desired dose, and this unit then compounds a one-week supply for the patient. This unit is staffed by 1-2 pharmacy interns and one pharmacist.

Dosis Unitaria - This unit serves the hospital’s inpatient departments. It is also the primary teaching department of pharmacy interns. This unit contains a centralized core staffed by a pharmacist, an intern who manages all other interns, and two other interns. They control the stock for the central core and distribute medications to the other departments. This department utilizes “drug carts” which are managed by interns and delivered to individual units to further dispense medications based on daily orders and status of floor stock. The departments serviced by this unit include neonatology, pediatrics, obstetrics/gynecology, general medicine A (men) and general medicine B (women). Neo, peds, and OB/GYN are staffed by four interns each, with four interns staffing medicine A/B.

The process begins with running inventory of the department and each individual cart first thing in the morning. Stock is replenished as necessary and then the drug carts are moved to their specific departments within the hospital. Interns await prescriptions from the physician and distribute medications to the nursing core or to the patient as appropriate. The interns return to the pharmacy at the end of their shift and complete an inventory review to assist with the next morning’s activities.

Medication Safety and Pharmacist Involvement

While in Perú, I developed a better understanding and appreciation for the measures that health systems in America have adopted to enhance patient safety and decrease medication-related adverse effects. For example, the primary vehicle for parenteral products in Perú is an ampule. However, one would be hard-pressed to find a filter needle. They are simply not used when drawing from ampules.

The pharmacist has a passive role in assisting with pharmacotherapy management and optimization. Although the pharmacists are consulted at times regarding adverse events and medication dosing, there currently is no regular review of patient’s allergies, drug-drug interactions, or response to current treatment. Before, I took these activities for granted in my health system.

Paper charts! To all my colleagues who practiced prior to computerized medicine, thank you. I have a brand new appreciation for the work you have done. As part of my rotation I completed a patient case presentation. All of my patient’s information, from physician’s notes, to labs, to the MAR, was in a paper chart. This meant that each bit of information I needed had to be searched for, manually, in this chart. As my patient had been there for two weeks, and had multiple complex problems, this was quite a tedious process.

The Patient Experience

Depending on the unit, there were between 2-6 patients per room. Privacy was a luxury not often given. This density of patients became even more apparent when we were amidst an H1N1 outbreak and had several patients test positive for TB.

Many items that you and I take for granted from our hospitals simply weren’t present and had to be provided by the patient’s family. These items include tissues, toilet paper, blankets, baby wipes, diapers, and even water.

Pain. This issue is at the forefront of many practitioners’ minds because it now affects CMS reimbursement. With the exception of my patients in ICU, I can count on two hands the number of times in two months I dispensed a pain medication. Patients rarely complained of pain during there stay. This further clarified a point that was taught to my class that pain is a very subjective indicator and can vary by patient population.

Pharmacy Education

Admissions

While in Perú I also had the opportunity to to attend courses at a local pharmacy school and learn more of the Peruvian education system. Near the end of high school (which lasts 11 years instead of 12), students take the Peruvian version of the ACT/SAT. When registering for the exam, students rank three career fields they wish to pursue in university. Based on the student’s score on the exam, the student is then placed in a program in one of Perú’s state universities. Should the student not score high to enough to be placed in one of their rankings, they can go to a private university. This option presents a problem for the student because it is more expensive. Also, students and graduates of private university faced a stigma: they were sometimes seen as unable to qualify for admission to the state school and thus inferior to state school graduates.

Curriculum

The students complete 5 years of didactic courses followed by one year of experiential education. Although from afar the Peruvian pharmacy education system seems similar to the American system, the Peruvian system appears to have a much stronger focus on basic science education. Peruvian students complete a significant research project and develop and subsequently defend a thesis. Students from the state school, after graduation, receive titles in pharmacy and biochemistry.

Financials

Students at the state school pay 400 soles per year, roughly $125. Students at the private university pay 2,000 soles, roughly $700. Although this is significantly less than the U.S. tuition range, the salaries are significantly lower as well. One can expect to make about $500-$1000/month as a pharmacist. The greatest facial expressions I saw during my stay were when I told people how much I pay in tuition as an American pharmacy student. Peruvian students simply cannot understand having to spend that much money on education.

Conclusion

A mentor once told me that “you have your comfort zone and you have where the magic happens. The two areas do not intersect.”

My experiences in Perú will have a far-reaching impact on my practice that I am still not able to completely understand. The situation was uncomfortable at many times, but I persevered. My experiences taught me about the health-care system and pharmacy practice in another country, about interacting with colleagues and patients of a significantly different literacy level than me (as I was far less fluent than my patients). I am forever changed by this rotation and encourage any students and practitioners out there who are looking for unique opportunities to step out of their comfort zone and spend time in a foreign health system. You can never truly understand your strengths and weaknesses until you take on opportunities like this.