A Rotation Abroad: Rural Pharmacy Practice in Southern Ecuador

Military trucks and alpacas aren’t the first things to come to mind when we think about pharmacy school, but I recently had the great fortune to complete an Advanced Pharmacy Practice Experience rotation based in Rio Bamba, Ecuador, during my fourth year of pharmacy school at Washington State University College of Pharmacy.

Every rotation in our curriculum is designed to foster growth, to challenge, and to shape student pharmacists into pharmacists. What’s the biggest difference between a student pharmacist and a practicing pharmacist? Knowledge base of course, but also confidence in their ability to make choices independently. No day in a pharmacy goes entirely scripted or without some hiccups, and when challenging situations inevitably occur, as healthcare providers it is our duty to solve them efficiently, professionally, and compassionately. Great pharmacists are able to achieve all of that, but also execute their solution with grace.

What sets my time in Ecuador apart from any other rotation that I’ve done or will do is that every element of growth, and every challenge is presented simultaneously. To be blunt, this level of intensity affords the student zero room to 'fake it.' All your mental energy is focused on providing a reasonable therapy alternative when 1st, 2nd, and 3rd line drugs, and drug combos are unavailable, while also ensuring a safe distribution process requiring management of ancillary staff who are brand new to working in a pharmacy, and working with translators to convey key counseling points to patients who do not understand your language. And when that process is finished, you struggle to figure out ways to more expeditiously execute these steps in order to provide medications to 160 patients in 5 hours in a shared, cramped space with folding tables for counters and water bottles for sinks.

There’s no standing around or acting busy, waiting for your preceptor to assign you work on this rotation. The preceptor isn’t hovering over every decision. Instead student pharmacists are allowed to construct their whole decision-making process independently with only the final product being verified as safe and effective. Work flow was entirely designed, run, and adjusted by the 4 students on this rotation. Everyone was working their hardest to provide medical care to people who, at the very most, receive it once per year, and more commonly have never received medical care. This was pharmacy at its purest—no counting robots, smart cabinets, computer systems, or phones, just patients with medication therapy needs. And we were the only ones for hundreds of miles who could provide the solutions.

Maximum growth occurs with maximum responsibility. We were afforded complete control over the pharmacy process and the freedom to make changes on the fly, as we saw fit. Fortunately, the 4 of us took our role very seriously. We were always running our ideas by each other, picking each other’s brain on anything and everything. Our first instincts to consult our reference books took us only so far, as commonly only 1st and 2nd line options were presented, neither of which would be available in our limited formulary. The limitations forced us to draw as best as we could upon 3 years of knowledge and practice, squeezing every pertinent pearl out of our collective brains. Every bit of useful knowledge that came out was much more permanently ingrained in our minds than any lecture or recall for a test question ever could. We were in the perfect independent, yet collaborative learning environment, the hard core version of 'think, pair, share.'

I’ve had time to reflect on every aspect of this rotation, to dissect the high points and low points. The difference between what you think about and what you share with others regarding a trip becomes very telling. I told my friends about the generosity and amicability of the Ecuadorian people, the food, the pharmacy aspects, but I never mentioned the times of anxiety, unfamiliarity, uncertainty, and ambiguity. Anxiety about the new, unfamiliar environment, uncertainty about the coming day’s events, ambiguity in our clinic patients’ signs and symptoms. These all weighed equally on my mind throughout my rotation.

Adjusting back to life in the United States took some effort. My efforts in Ecuador improved quality of life in immeasurable ways. Men, women, and children could work better, feel better, more ably take care of their families, and live fuller lives thanks to our interventions. And then just like that, we return to a world built on Twitter, Instagram, Snapchat, and Facebook, where our daily interventions are more similar to 'likes' and 'shares' with dubious effects on quality of life. Suddenly, the same priorities I had before don’t seem as relevant anymore. Sure, people always tell you there are people in need in the world, but until you actually work with some in the flesh, it’s easy to put far back in the mind until it no longer flags your brain’s attention as much as it should. This rotation was equally about personal growth as it was about professional growth.

Is this rotation for everyone? Maybe not. I wanted to get out there, to be put in the fire and come out sharper. I was looking for a challenge, I wanted to be pushed to my wits end, to have familiarity and comfort no longer be a crutch in my pharmacy education. Should every single student pharmacist put themselves in a similar situation or experience at some point in their education? Definitely. As we all know, pharmacy is a profession in which it can be easy to hide. Being in the back, behind the scenes, leads to relative anonymity and stable work hours can make it easy for some to do just enough. Just enough to collect a paycheck, to clock in solely with the purpose of clocking out later. Those aren’t the kind of pharmacists this country and this world needs.

After 4 years of pharmacy education, no one should be willing to settle for an end goal of mediocrity. I feel and I hope that this rotation creates only confident, ready to lead pharmacists, and I have complete faith in my pharmacy teammates to be leaders in the field. I knew them to be successful, talented, and hard- working before we embarked together on this rotation. But even then, we all saw the change, saw each other make it through the periods of uncertainty and emerge more capable on the other side. And in this way, we had grown together as well as individually.

I will remember this trip for a lifetime, and I will apply the lessons and experience gained throughout my pharmacy career, but what I will cherish most is the moments and memories spent with the incredible people of Ecuador, and the incredible people of the United States working together, side-by-side, overcoming great obstacles to try to help hard—to-reach people to be healthy. That, in the end, is the true bounty, the humanistic outcome that will always be weighted much more in my heart than a grade. It’s the reason why I chose pharmacy initially, and the reason I want to excel as a pharmacist in the future, a reason bigger than pharmacy itself.

Andrew Yabusaki is a 2018 PharmD candidate at Washington State University, College of Pharmacy.