Journal: exam finished

Yesterday morning, between 9am and 12.30pm local time, I and around 90 other midwives (I think) sat the exam.

The discussion at the university online forum and the fb site Graduate Diploma of Midwifery has been focused on relief.  The analogy to a difficult labour has, understandably, been made. 

The exam consisted of 18 questions, randomly allocated by computer for each student from a bank of questions.  There were multiple choice; true/false; short answer; and 'discuss the statement' questions.  I would have liked more time to complete the work - I spent more time than I should have on the early questions.  There were questions on pharmacokinetics, the absorption, distribution, metabolism and excretion of a drug; the therapeutic range for a drug; the changes in pregnancy when a drug is used, and what happens to the developing fetus.  There were questions that brought up polypharmacy, drug-drug interactions, genetic variances in enzyme activity, and social attitudes towards medication use in pregnancy.
 
I have nothing to compare this exam with, as it's the first of its kind, but I felt it was a reasonable test of the knowledge that should have been acquired over the past 5 months. 

As I have journalled my student experience since July 18 I have sought to look at the course, and my personal response to the challenges that it presented me with, objectively.  I put these things into writing as much for my own record as anyone else's. 

On the positive side of the ledger I have enjoyed learning the basics of pharmacology, and the application of pharmacology to midwifery practice.  I have appreciated the challenge to work on concepts that did not come easily to my ageing brain.  Visualising the microscopic processes which project molecules of drugs through the blood stream, across cell walls, and to target tissue is fascinating.  Remembering and revising basic science that I studied more than 40 years ago, understanding the constant movement of ionic charge from particle to particle, considering the anatomic function of the various body organs - this has all been good.  I have enjoyed it.  My friend Julie who I play tennis with most Thursdays is a high school science teacher, and she helped me revise the science of water solubility.

The less than positive side of what I want to record here is the lack of teaching by the university.  One tutor responded to calls for help, and presented helpful tutorials using the online webinar facility of the university.  With the wisdom of hindsight, I would encourage the faculty to offer a revision course for any students who are not up to date with current undergraduate midwifery knowledge in basic pharmacology - this applies to most of those for whom the course has been offered.  I think a series of lectures in the first month or so, using the webinar, would assist those students who have not studied at university in the past decade.  I have spoken in person about this to the head of the faculty for this course.

The ability to prescribe is still a little way off.  There is a further topic in the Graduate Diploma of Midwifery, Diagnostics and Investigations, which I will undertake in the first semester of 2013.  After that I will be able to apply for endorsement as a midwife prescriber.

I am thankful to the Commonwealth of Australia for the scholarship assistance that I have received. 


Thankyou for your comments

Journal: Preparation for exam

This week I am trying to spend some good time in revision of the core concepts that I will need, not just to achieve a pass mark in the pharmacology topic, but to consolidate the learning.

One of the main criticisms that I and other students have had as we approach the end of the course is that there has been a lack of teaching of the basics of pharmacology.  We are reading text books and academic papers, and for me the words and concepts of the science are often a confused jumble.

To address this deficit I have been watching a set of  lectures on Youtube

One of the faculty tutors hosted a webinar on Tuesday evening, and went through the practice exam that had been provided.  I found this very helpful.  A couple of points that were identified, at which I might improve my performance in the exam are:

• understanding how points are awarded: a question that is worth 2 marks towards the total score requires the student to make 4 statements (ie .5 each) that are relevant to the question.
• In multiple choice or true/false questions, a student will be awarded marks for each correct statement, whether it applies to the correct answer, or making the argument as to why a statement is incorrect or false.
• Clinical questions, such as discuss a pregnant woman who has a headache and wonders if she can take paracetamol, require discussion of the pharmacology of the drug in pregnancy, as well as the basic midwifery investigations, such as check the blood pressure, and question the cause of the headache.
• Polypharmacy is defined as the concurrent use of 5 or more medicines, which can include prescriptions, over the counter, and complementary.  For example, a woman who is receiving one prescribed medicine, such as oral antibiotics (1) for a chest infection in late pregnancy, may also take an antacid (2) for heartburn, raspberry leaf herbal tea (3) to achieve good uterine tone, an iron supplement (4) for anaemia, and pyridoxine (5) to treat mild fluid retention.  These substances will likely pass easily across the placenta to the fetal compartment.  What are the possible drug interactions with this group of apparently innocuous medicines?

Your comments are welcome.

Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Formularies

I went to the First national health professional prescribing  summit, which was held in Melbourne, Monday and Tuesday of this week.

I plan to record a few observations here, for my own future reference, and for anyone else who is interested.  The presentations are to be available at the conference site (with a password) after about 5 days.

It became clear to me as the summit progressed that formularies are likely to become bogs in which we get stuck.  This opinion was shared by well-informed people.  Already midwives have a formulary put out by the NMBA, another put out by PBS, and a third put out by each state or territory health department.   Someone has been employed to develop each list, and committees have reviewed and approved them. 

In practice an individual midwife, or other practitioner, has a group of medicines which we are able to work with.  This is the case with my practice now, even before I am authorised to 'prescribe'.  The problem with formularies is that the items listed are effectively taken out of professional scrutiny, and are used because they are available.  An example is the synthetic narcotic, Pethidine.  Pethidine has been used in hospitals for labour pain as long as I have been a midwife.  Without doing a literature review here, I have been aware for many years that there are good reasons for avoiding the use of Pethidine, and many maternity services have moved away from it.  Yet the formularies for midwives, developed by both the NMBA and the Victorian Health Department, include Pethidine. The formularies fail to ask critical questions, and it is quite possible that some midwives will interpret presence of a scheduled medicine on a formulary as a direction for its liberal use.

Don't get me wrong: I know very few doctors who have the same scruples as I do, restricting the use of 'dangerous drugs' to situations of clear need.  I know of very few instances where a doctor counsels people who have symptoms of upper respiratory infection that it is probably caused by a virus, and therefore won't be helped by antibiotics.  Yet almost every practitioner you talk to will easily mention 'evidence based' practice, as if the word equates to the deed.


Listening to the various presentations, I was aware that this is uncharted territory.  I made a list of words that kept coming up:

team, teamwork
collaborate, collaboration
partnership
credentialling
evidence, evidence based
protection of the public
scope of practice
competence, competency
standards
framework

Each of these words was brought into the discussion with, I am sure, the best of intention.  But each can be twisted into unintended meanings, and at times I have to shake my head and ask myself how does this particular theory fit my practice, or anyone else's for that matter. 

The government's reforms that are behind the expansion of non-medical prescribing have led to a flurry of activity, making up rules.  Midwives find ourselves with various formularies being developed in an attempt to 'protect the public'.  "What am I being protected from?" you may ask.  A midwife who is intentional about protecting, promoting and supporting natural physiological processes in childbearing and nurture will move into the world of prescribing medicines with a high level of caution, regardless of what the notation as a prescriber allows her/him to do.




Thankyou for your comments