Although I work in the hospital setting I belong to Medical Education

Although I work in the hospital setting, I belong to Medical Education Department which is responsible for the teaching of undergraduate medical students, undergraduate pharmacy students, Junior (Foundation 1 and 2) Doctors as well as Core Medical Trainee and Surgical Trainee doctors. My role within medical education is to teach these various specialities prescribing. I have always wanted to combine my clinical prescribing teaching with a more clinically focused role and hence why I applied for the Pharmacist Independent Prescribing (PIP) Module to facilitate this transition. In order for me to be able to teach prescribing, it is essential that I am able to educate my students on the various different aspects that go along with prescribing, such as examination of a patient, taking a comprehensive medical and drug history as well as looking at differential diagnoses. Without having been taught these myself, it makes my role as a teacher in prescribing more difficult as these principles are ‘out of scope’ of my daily working as a pharmacist. This qualification will not only provide me with the ability to transition into clinical practice and run anticoagulation clinics but will also serve as an important aid in my teaching. The speciality which I chose for my PIP module was Anticoagulation and VTE prophylaxis. This is a topic which I not only teach but Interests me greatly. I believe that due to the rise in numbers of patients being diagnosed with atrial fibrillation (Morillo et al, 2017) and with the availability and development of new therapies, it is a topic which has gained increasing traction and interest. Learning in Practice ReflectionTo reflect upon my module journal, I have decided to use the Gibbs (1988) reflection model to facilitate my development through reflection and evaluation of current practices in order to improve my methods and expand my competence in my area of expertise. During my period of Learning in Practice (LIP), I attended haematology clinics and wards rounds in order to shadow the various different healthcare professionals (HCPs) during their consultations/conversations with patients. I started attending the clinics and ward rounds at the start of the course which I had deliberately planned in order for me to get a head start and to become familiar with how the clinics and ward rounds worked. I was able to shadow a variety of HCP’s, ranging from Independent Pharmacist Prescribers to Clinical Nurse Specialists to Haematology Consultants. Having had the experience of shadowing various different grades of practitioners, I was able to learn the various different consultation techniques they used and how they would explain concepts and interact with the patient which varied upon who was conducting the interview. I was surprised by this initially, as I envisaged that the patient experience during their consultation and ward round would be similar irrespective of whom they were under the care of. Compared to all the consultation models available, The Calgary-Cambridge guide to the medical interview developed by Silverman, Kurtz and Draper is the one I feel the most comfortable in adopting and using as a template on which to structure my consultations on. This is because the method follows a very chronological order and by using both open and closed ended questions it allows the patients thoughts and feelings regarding their condition/medicines to be focused on in greater detail. The Five Year Forward Plan 2014, states that more could be done to involve people in their own health and care. It means focusing on what matters to the individual within the context of their lives, not simply addressing a list of conditions or symptoms to be treated. However, having had an opportunity to observe other styles, it’s become apparent that there are other ways to improve the method. I was able to observe the different consultation styles and this allowed me to formulate and develop my own consultation style depending on what I thought worked best. I added more questions and shifted the focus on the more holistic aspects of the patients life; their family, their work life, their support network etc. This helped me in deciding the best treatment option for them taking into consideration their lifestyle. Having patient’s more invested and involved in their health (particularly for those suffering long term conditions) challenges the traditional divide between patients and professionals and offers them better health outcomes through increased prevention (usually of side effects and disease progression) and supported self-care. All of the clinic patients were scheduled and therefore this allowed me ample time to review case notes, computer records and test results from the lab to enable me to have all the information prior to consulting the patient. I had noticed that all the practitioners that I had shadowed spent at least 30 minutes before the clinic start time to review all the case notes for all the patients and at least 5/20 minutes between patients to review the next patient. They also attempted to complete all the patient’s notes so that the majority of the allocated consultation time would be spent talking to the patient instead of filling in the notes on the computer. I feel this preparation is particularly important in conveying a professional image to the public and in making them feel heard and understood. Looking back at the consultation I have had as a patient with my own GP, very few of them were successful in my view. Due to time constraints, the GP was more focused on writing notes on the computer as I spoke thereby taking the focus off me which made me feel like I wasn’t properly being listened to. I had never paid much attention to this as my own time limitations prevented me from talking at length about my health concern. However, from reading about the benefits and successes of following a strategic consultation style, it made me wonder how much better informed the GP would have been had they have adopted the same approach to consulting. Attending the haematology clinics was a useful tool in helping me develop my own knowledge of alternative treatment options. Often the patient’s most seen in clinic were those who were to be initiated on an anticoagulant or those who would come in after having been started on warfarin or a DOAC with which they have experienced unwanted side effects. For patients who were to be initiated on an anticoagulant, I was surprised to observe the lack of available choices explained to them. From my understanding of the consultation process and medicine in general, patients should be explained ALL the treatment options available to them using Patient Information Leaflets for example including the benefits of each option and the associated risks so that a decision for treatment by the patient is informed. Ultimately a patient taking a treatment based on their preference is more likely to have sustained adherence to the treatment and therefore would lead to a better health outcome for them compared to patients who were not given a choice as they would most likely become noncompliant. NICE have produced patient decision aids for this very purpose. Most patients asked the following:1. What would happen if I missed a dose?2. Which one is better at reducing my stroke rise?3. Which one will increase the chances of major bleeding?4. What are the side effects of both options?5. Will I need regular blood tests?Question 5 for me is one of the most important as this not only affects the drug but the patient. For the first 3 months of warfarin therapy (or until INR is stable), the patient would have to come in twice weekly in the first few weeks then once every two weeks for another month and then monthly thereafter before transfer of care is moved to their GP. For a working individual or for those who have mobility issues (which is extremely common in the stroke patient’s) this can be very difficult and impacts their day-to-day life. People who work would have to take the day off and miss work as there is a long lag time between the bloods being taking in Phlebotomy to them being available in the clinic. For those who are older and have carer’s or meals delivered to their homes would have to give notice to their carer or meal delivery system otherwise they would be left without care or without a meal having missed their “slot”. Hence the majority of patients were heavily discouraged to start warfarin and were advised to start a DOAC instead. DOAC’s despite their lack of monitoring required and their ease of administration regime do have their drawbacks and these were not properly explained to the patients in my opinion. However, as a potential practitioner, I can understand the difficulty in navigating the fine line between patient autonomy and cost. It is something which I reflect upon often and it is something which I will no doubt keep in the forefront of my mind when I begin to consult my own patients. Being an educator on anticoagulants, I have reasonable knowledge on the different oral anticoagulants available and their applications. During the consultation I would often try and work out the best option in my head to see if my treatment option mirrored the one chosen by the practitioner. This however required me to know the pharmacokinetic and pharmacodynamics properties of the drug in depth as well as having an extensive awareness of the information contained within the medicines Summary of Product Characteristics which I became quite familiar with from my reading. I was therefore already practicing my decision making skills and adding to my existing knowledge of alternative treatment options. I found that having to decide the best treatment in the space of the length of the consultation was rather difficult and I had to refer to my “cheat sheet” (a list that I had put together with all the different oral anticoagulants, their doses, side effects, renal parameters etc.) quite often. In time, I think I would become more familiar with the options off-hand and be able to simply refer to the cheat sheet if I absolutely had to. During the ward rounds, I would shadow the Specialist Anticoagulation Pharmacist, Consultant Haematologist and Specialist anticoagulation nurse. Prior to the ward rounds, we would print off the patient referral sheets and the health care professionals would review each patient on their own and annotate on the sheets if there was anything that needed to be discussed with the team (complex patients) or what additional information they would need from the medical doctors or nurses e.g. correct weight. We would typically see between 4 to 8 patients in the mornings. The ward rounds offered me a completely different perspective on the patient consultation. Usually, the patients were unable to communicate (due to suffering a recent stroke for example) or were unconscious. It was therefore largely upon the HCP’s to discuss as a team what they felt would be more suitable. A recommendation would then be made on the computer so the regular doctor could amend the prescription (or continue existing treatment) and the nurse would attempt to counsel the patient on the medicine being proposed. This worked well as the consultant would be responsible for filling out the information required on the computer whilst the pharmacist and nurse would counsel the patient and confirm with the ward nurse any particulars. The communication between the members of the MDT was seamless and there was no superiority/inferiority; each professional brought something to the table and this was a prime example of how patient safety is a key driver in forging these relationships between different HCPs. Throughout my LIP, I was fortunate to attend a variety of anticoagulation and VTE masterclasses (INNOVATE, X-IMPACT, JoMO) run by the UK CPA and/or pharmaceutical companies (namely Bayer). The X-IMPACT series of meetings is aimed at clinicians within primary and secondary care who are confident in prescribing a non-vitamin K oral anticoagulant (DOAC) in the area of AF and VTE management and wish to share best practice, real-world case examples and experience of practical management amongst peers.There were various guest speakers from all parts of the UK who specialised in either Cardiovascular, Stroke and/or VTE and thrombosis. The focus of the meeting was to shift attitudes in the diagnosing and treatment of AF. One of the topics discussed at the event was the importance of using CHADS and HASBLED in determining risk and how to use these guidelines to practically asses bleeding and stroke risk in patients whom anticoagulation has been suggested.Another large topic of conversation was how to dispel the myths associated with DOAC prescribing and overcoming patient’s perception of DOACS and warfarin. There were many clinicians in the room who were from primary care and they were discussing how the newer agents have impacting clinical practice and made the process much smoothing especially due to the lack of monitoring required and the costs associated with running warfarin clinics. This for me was the highlight of my LIP. I was able to discuss, contribute to, and reflect upon anticoagulation as a whole concept, not soley focus on AF or VTE. I had the opportunity to talk to professionals from all backgrounds and from all different specialities which was rare when working in haematology as its usually cardiologists and geriatricians who you consult with. With the wealth of knowledge I obtained from these seminars I was able to contribute more confidently in ward rounds and link clinical trial data to complex cases where analysis of the data contained in the trials was essential. Residential week reflection I found the residential week extremely useful, in not only my personal development but also my professional development. The written OSCE allowed me to use my decision making skills, time management skills, and most importantly my assessment skills. The fact that in every station, more and more information was given to us to help us make a decision is reflective of real life where information is constantly being given to you and sometimes at the last minute. It can sometimes be overwhelming to deal with lots of different pieces of information as it was so valuable to be able to practice skills to help us deal with this as prescribers. Apart from dealing with the clinical aspects of the patient, a more holistic view needs to be taken in order to fully propose the most effective and appropriate treatment for the patient. The OSCE station where we had to write a prescription was useful as pharmacist are often simply use to checking scripts and therefore having to write a script legally would have been a massive change in practice. In my field I would not be expected to prescribe products such as biosimilars or opioids, however having an awareness of the legal and clinical responsibility associated with prescribing them is still required. Re-reading legislation outlined in The Human Medicines Regulation 2012 (namely regulation 217) and Misuse of Drugs Regulations 2001 refreshed my knowledge on the legal particulars.Whilst completing the paperwork for the IP Portfolio, there were often times where I would have to stop writing/typing to really think about what I was writing and more importantly WHY I was writing it. Every interaction I had with a patient (outlined in my learning outcome document) taught me something new; whether it was regarding clinical knowledge, consultation skills or simply behaviour to patients and other HCP’s. Clinical knowledge is easy to grasp for me, and gaps in my knowledge can be addressed by research and reading. Changing your behaviour as a practitioner and person and adopting these new behaviours in working practice is considerable harder. Every entry I made to the learning outcomes document and competency framework allowed me to reflect upon how much I have changed my practice and behaviour based on these interactions with these patients. For me, it wasn’t about simply ticking off the competences, it’s about how the competencies taken as a whole have directed me into practicing better as a HCP. Conclusion I found reflecting on my experiencing in my LIP extremely thought provoking and allowed me to consider my own experiences in applying knowledge to practice (SchÖn, 1987) and I now have a deeper approach to learning and developing as a practitioner. I have learnt how to communicate better and more effectively especially in patients who cannot communicate back, I have learnt how to be patient with patients and to give the benefit of the doubt to those who I have interactions with. I have most importantly learnt how to manage my time whilst still being able to fully consult on all the important points in a patient’s care which is something that I envisage every practitioner to struggle with. I have been humbled by the patient’s I have met and consequently have a better understanding on the importance of compassion, empathy and offering the patient support. Because of this I will continue to attend ward rounds and clinics on top of my usual working responsibilities as I have benefited more than I could have imagined.

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