The human touch: oncology pharmacist Jo-Anne Yap on working with cancer patients
On the ground, many long and difficult battles against cancer require multidisciplinary teams of healthcare professionals, including nurses, technicians and pharmacists. MIMS Pharmacist speaks to oncology pharmacist Jo-Anne Yap to find out more about her experiences over two years in the chemotherapy ward of a private hospital in Kuala Lumpur.
Tell us about your daily routine.
Actually, as an oncology pharmacist you basically do everything that needs to be done. (laughs) It’s almost the same as operating a normal pharmacy, no matter if it’s inpatient or outpatient. Although the patient load may not be as much, we have to cover their treatment from the top—when they start chemotherapy—until the end where they go home with their medication.
I work at the CDR pharmacy—short for cytotoxic drug reconstitution, where we have a clean room to reconstitute chemotherapy medication. Early in the morning we clean [the room] with special tools and get it ready to be operational. When the patients start coming after they see the doctors, we receive their prescription from chemo daycare, screen them, prepare the work sheet labels, then proceed to reconstitute the medication for IV chemotherapy.
For oral chemotherapy, it’s 100% bedside dispensing. It’s very different from normal medication like blood pressure or cholesterol tablets; there’re certain cycles/periods to take in the medicines. So, it involves a lot of counselling and really understanding how the patients are doing while on their medication. There are a lot of side effects, so we have to know: are they doing well, or having any problems? We also do counselling for patients on intravenous (IV) chemotherapy.
I’m also involved (in) educating staff in the unit, these include pharmacy assistants and junior pharmacists. First of all, they have to know their aseptic technique. Also, I have to enforce in them the knowledge of dealing with hazardous medication. If you don’t handle it properly, there may be harm to the personnel involved in handling it, and also to the environment. Other people not involved in CDR pharmacy might get exposed also, and there’s a chance they might get side effects from those hazardous medicines.
Was there any additional training you needed?
Not really. I previously worked in inpatient/outpatient pharmacy, and I’ve learned a lot from my senior before me. There’s a lot of self-study, referring to guidelines, and also talks and CME given by companies; and every year there’s this oncology summit where we get a lot of information on new treatments or products. My personal experience is more like—I pick up, I study a lot on my own. If you don’t understand anything, you call the oncologist and ask.
Tell us about a challenging situation you’ve faced.
Working in a private hospital, treatment-wise, dealing with patients and doctors, [there’s] not a really big problem for us, but… [when it comes to] money in treatment, it’s very hard for us to break it to them sometimes: “Okay, this is a really expensive medicine, but you need to be on this medicine for as long as you can.” One time the patient told me: “I don’t think I got the kind of money to be on that medicine for so long.”
For a normal patient on normal therapy, maybe they can expect to be on a medicine until they get better. But chemotherapy is different; sometimes the patient will have to be on that medicine for as long as they can until their cancer progresses which, more often than not, will progress.
It’s not a challenging situation so much as one of the downsides. It breaks your heart sometimes, because—[even though] you don’t really know them, and more often than not, this happens on the first dispensing, because they’re a new patient, so it’s the first time I’m talking to them… but it’s something you have to deal with.
And then sometimes it’s like—oh, this patient came last week for her Cycle 4 chemotherapy, and her [next] chemotherapy is supposed to be 2 weeks later. And then 2 weeks later I’ll be asking: “Hey, how come they didn’t come for chemo?” And [my colleague] will say: “No more already.” Sometimes it’s really bad. It’s very fast. It could be difficult if you’re someone who’s very attached to patients.
Is there any particular thing(s) you do to support yourself?
Well, I only go and see the patients when I dispense medication to them, or sometimes when I just go up and check their file, or chat with them. The nurses’ part is even closer. Every cycle [the patients] come, the nurses will attend to them from the start of chemotherapy until they’re discharged to go home … so they are more attached.
A lot of support I get is from chemo daycare itself. The nurses there, the assistants there, sometimes the doctors there. If I need any support, I’ll go up and talk to them. Because if something didn’t go well, I want to know the answer. Did something happen? Or was the chemo not appropriate at all? But I’m sure the oncologists there already review everything.
It’s really the whole oncology unit. We talk to each other a lot when we work.
Have you known cases of patients going into remission?
Yeah, there are cases where the cancer got cured--- or rather they are in full remission. I wouldn’t say the word “cure”, because I can’t use the word in front of a patient—they’ll take it the wrong way. “In full remission” means there are no traces of the tumour, or there’s no tumour marker in their blood tests or scans.
After they’re in full remission, they’ll come in for annual checkups. Because there’s nothing wrong with them, I won’t go and see them, but I do meet them sometimes over the counter or at the registration counter. You can see a glow in them every time when they come back. (laughs) They’ve got a very happy-go-lucky kind of attitude. “Yeah, doctor says no problem, see you again in 1 year’s time!”
For us, we’re also very happy to say—instead of “see you again in 3 weeks’ time for your chemo”, I’d be very happy to say: “See you in 1 year’s time, no need to come back so often.”
Any particular message to share with pharmacists interested in this area?
You learn a lot of things as you work [in oncology pharmacy]. Cancer treatment nowadays, there’s a lot of advancements, so if you’re interested in newer therapies, clinical trials, then it’s actually quite an interesting unit. There’s a lot of things coming in and phasing out, so the regime is different as time goes by.
It can also train you to be more careful when you work. Because you cannot screw up something with [a patient’s] treatment. IV chemotherapy is something that, if dosing is done differently from what the doctors prescribed, the consequences are very bad. So, it really trains you to be a more meticulous person.
Patient-wise, you become more empathetic. I remember when I first started, it was just dispensing; I’d tell them: “These are the side effects you’re going to get, okay? Alright, that’s all, I’ll see you in another 3 weeks.” Now it’s like, when I go up: “So how are you?” I won’t tell them about the side effects, I’ll let them tell me how they feel about their chemotherapy.
Really, it changes how you … it trains you to have a conversation, to care more for the patients rather than: “Here’s your blood pressure pill, your diabetes pill, okay you can go home, you come back one month later for your refill” and then that’s it.