Letters

Letters Multiple mini-interviews for pharmacy residency candidates

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e read with interest the recent article by Oyler et al.1 describing the incorporation of the multiple mini-interview (MMI) technique into their postgraduate year 1 (PGY1) pharmacy practice residency interview process. We implemented the MMI into our own PGY1 interview process in February 2014. In previous years we had conducted three 30-minute group interviews with each candidate in addition to other activities (e.g., lunch with current residents, hospital tour). This year we reduced the number of traditional group interviews to two 20-minute interviews and included three MMIs per candidate. We developed three MMI scenarios. Each candidate was given 2 minutes outside the interview room to review the selected scenario, followed by 8 minutes in the room with the interviewer. In contrast to the process described by Oyler et al., we elected to have one interviewer conduct the same MMI scenario for all 29 candidates in an effort to maintain consistency in scoring. Each MMI interviewer was oriented to the process before the interview period. Interviewers did not review the candidate’s application packet before, during, or after the MMI. On the day of the interview, interviewers were

provided with a scoring sheet that included key points for discussion and suggested prompts to help foster a conversation and aid in grading. Each candidate was given a subjective score on a scale of 1 to 10 for each scenario. These scores were then combined with those from the traditional group interviews. We chose to weight the mean MMI and the mean traditional interview scores equally for each candidate to determine the overall interview score. We found that interviewer scores for traditional interviews were on average nearly 1 point higher (7.7) than for the MMI (6.9), though this difference was not significant. Similar to Oyler et al., we surveyed our interview candidates regarding the inclusion of the MMI in the interview process. An anonymous Web-based survey was sent to each candidate after final match rankings were due and before the match results being released. Thirteen of the 29 candidates completed the survey, and 4 (31%) reported interviewing at institutions using the MMI format aside from our own. All respondents thought that the MMI topics adequately reflected their knowledge of pharmacy practice. We also surveyed candidates with regard to the logistics of administering the

The Letters column is a forum for rapid exchange of ideas among readers of AJHP. Liberal criteria are applied in the review of submissions to encourage contributions to this column. The Letters column includes the following types of contributions: (1) comments, addenda, and minor updates on previously published work, (2) alerts on potential problems in practice, (3) observations or comments on trends in drug use, (4) opinions on apparent trends or controversies in drug therapy or clinical research, (5) opinions on public health issues of interest to pharmacists in health systems, (6) comments on ASHP activities, and (7) human interest items about life as a pharmacist. Reports of adverse drug reactions must present a reasonably clear description of causality.

MMI. All respondents thought that the instructions provided beforehand were adequate. Four thought 2 minutes was too little time to review the scenario before entering the room, while the remaining respondents believed that 2 minutes was the correct amount of time. Ten candidates (77%) responded that 8 minutes was the correct amount of time for the actual interviews, while 2 (15%) thought that the interviews were too long and the remaining 1 (8%) believed that there was inadequate time for the interviews. Based on these responses, we are considering extending the time to review each scenario before entering the room. Finally, we assessed candidate preference for the MMI. Survey respondents were relatively divided with regard to how stressful or intimidating they found the MMI compared with the traditional interviews. An equal percentage (38%, 5 respondents) found the MMI to be more stressful or intimidating than the group interviews or no different than the group interviews. The remaining 3 respondents (23%) found the MMI less stressful than the group interviews. As described by Oyler et al., the MMI appeared to be a positive experience for our candidates. The majority of respondents (85%, 11 respondents) believed the use of the MMI would not affect their ranking of our program, while 2 (15%) said the use of

Short papers on practice innovations and other original work are included in the Notes section rather than in Letters. Letters commenting on an AJHP article must be received within three months of the article’s publication. Letters should be submitted electronically through http://ajhp.msubmit.net. The following conditions must be adhered to: (1) the body of the letter must be no longer than two typewritten pages, (2) the use of references and tables should be minimized, and (3) the entire letter (including references, tables, and authors’ names) must be typed double-spaced. After acceptance of a letter, the authors are required to sign an exclusive publication statement and a copyright transferal form. All letters are subject to revision by the editors.

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the MMI caused them to rank our institution higher. Overall, the MMI was successfully implemented at our institution. Feedback from the interviewers was generally positive. Having one interviewer conduct the same scenario throughout the process allowed for a better comparison among candidates, which we think is important. In addition, the interviewers were able to provide opinions of the candidates without being biased by information found in the application packet. The interviewers thought that 8 minutes was occa-

sionally too long for some candidates. We concluded that the MMI format allowed the program to gain information about the candidates that was not gained in traditional interviews, such as clinical knowledge, knowledge about the profession of pharmacy, and critical thinking skills. Going forward, we plan to use the MMI format with a few minor adjustments based on the feedback described above. 1. Oyler DR, Smith KM, Elson EC et al. Incorporating multiple mini-interviews in the postgraduate year 1 pharmacy residency program selection process. Am J Health-Syst Pharm. 2014; 71:297-304.

Potential pitfalls of basing specific antibiotic therapy on rapid susceptibility reporting

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he recent article by Geiger and Brown1 regarding rapid susceptibility merits comment. In the real world of clinical medicine, physicians often respond to positive culture results, which do not necessarily represent infection, with antibiotic therapy. They do so without assessing the clinical significance of the results—whether, for example, they represent colonization versus infection—as if the results themselves demand a therapeutic response. Rarely is there any consideration of the clinical relevance of the organism at the body site cultured. Physicians often have difficulty differentiating colonization from infection in specimens from sites that are commonly colonized (e.g., respiratory secretions from intubated patients, urine from indwelling urinary catheters, samples from sacral decubitus ulcer wounds). The purported advantage of rapid susceptibility reporting is that it permits early specific therapy, but rapid reporting does not address the critical issue of siterelated clinical significance. The prescribing of antibiotic therapy as a reflex to the rapid reporting of clinically irrelevant isolates (colonizers) is, at the very least, problematic.2 1246

Useful applications of rapid reporting would be in differentiating methicillinsensitive Staphylococcus aureus (MSSA) from methicillin-resistant S. aureus (MRSA), and vancomycin-sensitive enterococci (VSE) from vancomycin-resistant enterococci (VRE) in bacteremias, but even these applications may not be cost-effective.2,3 For MRSA, an important problem in testing is the potential discrepancy between in vitro susceptibility and in vivo effectiveness.4,5 For S. aureus skin abscesses with MSSA or MRSA, the primary therapeutic intervention is surgical drainage.2,3 In hospitalized patients, MSSA or MRSA cultured from respiratory secretions in intubated patients, from decubitus ulcers, from nonpurulent wound drainage, and from urine obtained through indwelling urinary catheters almost always represents colonization and ordinarily should not require antibiotic therapy. Rapid susceptibility testing, by its very speed, encourages a rapid antimicrobial response by physicians. Similarly, VSE or VRE commonly colonize urine samples obtained via indwelling urinary catheters and represent catheter-associated bacteriuria (CAB). In normal hosts, the initial approach to

Am J Health-Syst Pharm—Vol 71 Aug 1, 2014

Michael L. Hurtik, Pharm.D., BCPS, Clinical Pharmacy Specialist [email protected] Christopher A. Paciullo, Pharm.D., BCPS, Postgraduate Year 1 Residency Program Director Pharmaceutical Services Emory University Hospital Atlanta, GA

The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140227

CAB is to change or remove the catheter rather than to institute specific antimicrobial therapy on the basis of rapid susceptibility testing of urine colonizers. If oral therapy for CAB with VSE or VRE is desired in immunocompromised hosts, rapid susceptibility testing is not essential, since nitrofurantoin is an effective oral agent for both VSE- and VREassociated CAB. Specific, as opposed to empirical, therapy purportedly reduces antibiotic resistance and is part of the rationale for rapid susceptibility reporting in antibiotic stewardship programs. However, acquired antibiotic resistance is agent specific and not related to an antibiotic’s class or spectrum. Using narrow-spectrum or specific antibiotic therapy does not decrease resistance potential per se.6,7 The treatment of MSSA soft-tissue infections with cefazolin has no more resistance potential than treatment with the more-specific agents oxacillin and nafcillin. Clearly, using ceftriaxone to treat community-acquired pneumonia caused by Streptococcus pneumoniae is not more likely to promote resistance than morespecific treatment with penicillin. While rapid result technology is remarkable, be careful what you wish for. Rapid susceptibility testing, particularly with reference to the examples given here, has yet to be shown to be clinically mean-

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Multiple mini-interviews for pharmacy residency candidates.

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