Sunday 22 October 2017

First Step In The Right Direction

Week 2 - Internship
It is now 2 weeks since we set foot in the hospital though we should have reported by 3rd October, 2017 making it 3 weeks. This second week, we had fairly gotten familiar with the place and how activities run. So we were up to the duties expected of us. Though with the much will to get done as we would have loved to, sometimes reality checks in and sometimes we just got to do what we can do to the best of our abilities. For instance, on the first day, I planned to be at the pharmacy by 8am so I am able to stock take for 1 hour and thereafter, do ward rounds and plan on how to follow up with my patients thereafter. I had no idea that stock taking and updating of the stock cards would take most of the morning hours. Before I knew it, it was close to 1pm. My work being interjected with occasional dispensing to patients. So I had to juggle between stock taking and intermittent dispensing meds. In order to be efficient and deliver results, we saw it fitting to meet as intern pharmacists and plan on how to go about with our activities and how to jointly conduct pharmacy rounds given the challenges of having inadequate preceptors. Indeed, we had a fruitful meeting despite not being able to conduct the ward rounds as I had planned.

Prior to the start of the internship, I took a short online course offered by the Institute for Health Improvement ( focusing on a  Model for Improvement, as well as one I am still taking called Leadership and Organizing for change. As it turns out, this week, I have had the opportunity to test some of what I learnt in relation to effectively planning as well identifying colleagues and sharing about how to organize for possible changes in addition to what we learnt while at University.  

4 important things happened this week. The first one was my interaction with the in charge Nurse which revealed to me what our predecessors had done. Sister In Charge, as they are popularly called here, came to Level 6 pharmacy where I was. Apparently, the pharmacy had been closed for a week ever since our predecessors had already signed out. To find the pharmacy open was something exciting. It was clear from her warm greetings and exchange of pleasantries that our presence as intern pharmacists was anticipated to fill a gap. Sister, told me how our predecessors, especially the one on Level 6, where I was, always came on time, did bedside dispensing, followed up her patients and made recommendations to them and patient care had improved. She told me of one of the scenarios where one of the medicines, Piperacillin/Tazobactam better popularly referred to as PISA had been prescribed to a patient yet regrettably the patient could not afford the full dose. As is the case many times with most Ugandan hospitals, these drugs are usually out of stock and PISA did not miss out on these list with the most available drug being ceftriaxone. The alternative switch which had been done was to treat the patient with 2g of Ceftriaxone for a couple of days yet no much positive effect was being noticed. The then intern pharmacist, suggested to the team that rather than use 2g Ceftriaxone the dose be stepped up to 4g with daily monitoring after assessing all aspects of the drug in relationship to the medicine in question (2g Ceftriaxone is usually the dose prescribed, and not 1g ceftriaxone due to reasons of efficacy), Indeed, in the consequent days, true to her word, the patient had considerable improvement which was very appreciative of her. 

This small acts of commitment of my predecessor had earned her reputation in the ward as being very resourceful. “Will you be like your predecessors,” Sister asked me to which I responded in the affirmative. Listening to the positive feedback given by the Sister in Charge came at the right time as it provided me with the positive energy to follow. To get to learn of how interested the sister in charge was willing to cooperate with us was indeed heartwarming and I look forward to working closely with all of them.

The second thing that happened was the first debriefing that we did after doing our first joint pharmacy rounds as Intern Pharmacists on the General Gynecology ward. We evaluated what went well on the rounds, what we would need to improve next time and test changes to try out. Indeed, though we surely have a long way to go, I am positive that we have started in the right direction. One observation was the importance of establishing rapport with the patient to allow them open up while taking history. This meant introducing ourselves and reason for why we wanted to interact with the patients lest you could be sure that the patients would keep secret their challenges for fear of not knowing who we were. We hope that in our consequent interactions we shall be able to put into practice the recommendations based on what was observed.

Debriefing after our first Joint Ward Round: Komakech Walter sharing his reflections of how the Joint Pharmacists Ward round went to fellow intern pharmacists seated and attentively listening

Thirdly, as we settled in, we have been honored to have diploma pharmacy interns join our team. As we got oriented last week, this week, we have been busy orienting our colleagues, the pharmacy technicians who have increased on our slim numbers which promises better efficiency in allowing us better follow up with patients as they help with dispensing the meds at the ward pharmacies. Less than a month so far, the challenge we already identified has been the much work expected of us despite the fact that we are only 6 intern pharmacists each one responsible for a level in the 9-level storeyed Hospital, directorate of Obstetrics and Gynecology, Mulago Hospital

The interaction with physicians while at university generated two impressions, one being positive sometimes and at other times negative. In this setting, we have had a series of discussions with some of the intern doctors and the positive attitude and willingness to work together is worth writing about. One of the intern doctors wondered why he was not always seeing pharmacists on rounds yet he would have loved to see us always be part of the team. It is sometimes very easy to blame a party for not doing what is expected of them not until when you engage them and hear their side of the story then a more rational conclusion can be made. This engagement with our medical colleagues unpacked the shortcomings that needed to be bridged so as to get pharmacists more resourceful and a more harmonious relationship established. Whereas it may be true that the doctors of yesteryears might find it challenging to accept the vital roles the pharmacists play as part of the health care team, the new breed of the medical doctors will find the pharmacist indispensable in providing pharmaceutical care with the patient being at the centre of focus for the best possible health care to be provided. It has been a week of learning and scanning where, how and when we as pharmacists can collaborate with all the rest of the healthcare team to provide better patient outcomes.

Pharmacy Education In Africa; A Lens from sample countries

Week One - Internship

Jotting down this experience reminds me of the essay we were told to write in high school in the English class. Our then English teacher, referred to it as my first day in secondary school. In this case, it would come off as “My first week doing internship:”

The first week spent at Kawempe Hospital would be better referred to as orientation week. We were welcomed and had a short tour of the 9-level hospital, Mulago National Hospital ‘s directorate for Obstetrics and Gynecology for the mean time since the main hospital is under renovation. I have been placed to work on level 6, a level housing the Highly Dependant Unit, Oncology section, General Gyn, and Urogyn units. 2 Intern pharmacists placed on level 5 where the volume of patients seen is highest. Level 1 in which there is the OPD unit, level 4 housing the delivery suite and level 7 dedicated for patients who pay for all the services out of pocket all have one intern pharmacist in charge of the pharmacy unit.
An Intern Pharmacists Selfie moment during the Hospital Tour

As is the norm, the tools of work such as the stock cards, dispensing log books, stock that remained after the previous interns left were handed to us and we were officially handed the mantle to start our 1-year long internship program. Week 1 was also an opportunity to get to know our colleagues better.3 of my colleagues pursued their pharmacy education from Algeria and one from India while the 3 of us all studied locally in the same university. I came to learn some interesting facts about pharmacy education in Algeria. 

Apparently, Algeria offers both Doctor of Pharmacy programmes which is a 7 year program and bachelors of science in Pharmacy programme which runs for 5 years. Regardless of which path an individual chooses to take, he/she ought to learn French, the language in which the courses are taught, in the first year exclusively rendering the first year basically for learning French. No doubts my ability to speak French could not match their fine mastery of the language. One of them offered the PharmD programme while the latter offered the BPharm programme and so I was curious to know what was unique about the 2 courses.
What stood out in my interaction with these folks was the extent to which they had studied modules related to medical laboratory work as they detailed their knowledge in parasitology, microbiology, clinical chemistry and other related course units. Had they pursued these related course units in Uganda, they would pass off more as Medical Lab scientists than Pharmacists. It was more surprising to learn that pharmacists in Algeria were allowed to open medical laboratories to perform some of the laboratories to carry out the medical investigations synonymous to what medical laboratory scientists do here in Uganda.
Group Photo of the Intern Pharmacists; Back Row from Left;m Komakech Walter, Nabuuma Mariam, Kyambadde John .M.
Front Row: From Left: Aboda Noah, Nantege Rachel and Namukasa Flavia
Unlike our foreign trained colleagues, our learning leaned towards more hospital based pharmacy roles such as provision of pharmaceutical care, pharmaceutical analysis in industry and developing a better understanding of use of natural products or herbal products in the management of diseases. Like Algeria, India also runs a dual pharmacy program in which both the PharmD and BPharm curriculum are run. With all this diversity in education, we can only hope for a richer interaction sharing experiences and getting a better sense of how either parties can benefit from these varied learnings.