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.




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