The Big Debate

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The Big Debate #2

Started 9 months ago

Good evening everyone and welcome to our second Big Debate. Tonight we'll be debating whether provisionally-registered pharmacists should still have to take the registration exam.

2020 has been a difficult year for pharmacy teams in general - but spare a thought for this year's pre-reg cohort, who've had to endure a particularly intense year in practice as well as months of uncertainty over when the postponed 2020 registration exam will be held. Earlier this year, the GPhC announced it would allow pre-regs who met "certain criteria" temporarily join the register to help out with pharmacy's COVID-19 efforts. However, these "prov-regs" will still have to take the registration exam when it is expected to be sat sometime early next year - despite having been practising for several months.

So, should prov-regs still have to sit the registration exam? Do you think it's only fair, given all other recent cohorts have had to sit the exam, or have prov-regs already proven their competency to stay on the register? Let us know your thoughts by commenting below. The debate will formally be closing at 8pm, but feel free to continue the debate for as long as you like.

The exam is there for a reason. It is there to ensure that there is a minimum standard of competence for those who are practising. It has nothing to do with being there "just for the sake of it". More importantly, it allows the public to have confidence that a person who has sat the exam and has passed is competent to practise. The GPhC are there to 1. Protect the public, 2. Maintain public confidence in the profession and 3. To maintain and declare proper standards within the profession. The exam fulfils all 3 of these criteria.

Would continuous assessment throughout the year be better than an exam?

I believe the registration exam should still be sat, and the biggest reason for this is the lack of quality / consistency in the current pre-reg system. 

My pre-reg tutor was absolutely fantastic, and I would say this for the vast majority of pre-reg tutors. However this is not 100% across the board. Every year I also see pre-regs voicing their dissatisfaction of the year - bullying and/or used as simply as a pair of extra hands. A common thread is, a pre-reg not speaking up in fear of not being signed off from their tutors. Furthermore, there is not enough standards to become a pre-reg tutor. How do we ensure there is robust quality of teaching / assessment / mentoring / coaching abilities? The exam provides a different assessment to have confidence in a registrants ability. And because of this, I believe that not sitting the exam could affect the publics confidence in the profession.
However, it does annoy me that some pharmacists believe prov-regs should not be allowed to practice, due to not sitting an exam. The pandemic was an unprecedented event and prov-regs should not be penalised for initial education and training that is not fit for the 21st Century. Would you say to someone in person (when you are able to!) that they are less of a pharmacist for not sitting an exam? If not, why say this at all?

Interesting points so far. I know lots of prov-regs feel that this year has felt like one long assessment - do you sympathise with that view?

I have discussed this in depth on Twitter and I keep on coming back to the same answers and importantly, one answer sticks out a mile. The Prov Regs signed up to this deal so they knew what it entailed and that an exam would be forthcoming. My esteemed colleague, Greg Lawton, has also posted extensively on this. The exam is not perfect and I am more than willing to concede that but it is what it is. There are many many pharmacists who have read for other degrees after qualifying. All done in their own time. There is also the argument that other professions have given registration to their registrants without any further competency based assessments. That is other professions and not pharmacy.

I agree that the exam is not there just for the sake of it and it has some purposes. However, I do believe that it is currently causing more hinderance in regards to so many aspects a) our mental health and b) our professional progression. It is true that we are allowed/we have started our diplomas and equivalent however it is very difficult to balance between our jobs, pre-reg revision and our professional progression.   

Moreover, the clinical aspects of the BNF are very generic - and in practice we do not even use that (e.g. local guidelines, renal drug database etc.). The exam does not reflect on that. 

All other professions cancelled their exams (e.g. medics and nurses) - except for pharmacists and that was very disappointing. I believe that they also care for patient safety however they trusted that their practitioners (pre-reg equivalent) would manage.

Ofcourse they need to sit an exam 🙄😂

In response to Nahim above, the points that you have made about the current system are very valid. However, the exam was introduced back in the 90's to ensure a minimum competency after dissatisfaction was aired regarding the previous system of sign off at 52 weeks. Dame Janet Smith briefly explored the evolution of the current system in the Shipman Reports and it was brief but worth a read. Prov Regs should be allowed to practise but if they sit the exam and do not pass, then they should be removed from practise until such time was they can successfully pass the examination.

@Ruby Akkad you make a good point - does it undermine the perception of pharmacists as other professions have cancelled their exams?

Ruby makes an interesting point about further education. Is prepping for the exam not "further education" and therefore, the revision for the exam should be done in your own time? You would be expected to revise in your own time for any examinations or testing for a further degree. Why is this so vastly different?

@Naimah - the fact the pre-reg exam should be seen as bolstering the profession as the public can be confident that those who pass and are allowed to practise have a baseline competence that has been objectively assessed. You cannot say the same for those other HCP's who have been entered onto their respective registers without any objective assessment. 

Paul, in response to prov-regs have signed for that, I would just like to state that this was either that or staying at home waiting for the exam to come. It was a temporary solution, to a problem - the problem  [the pandemic, the situation "lockdown"] is not resolving anytime soon. It is not like we had choices or a say in any of the decisions taken by the GPhC. The simplest proof is pre-regs who had to re-take their exam and are now left stranded for almost ~6/12 . 

As for the point regarding the "further education", yes, I do not think prepping for an exam is considered further education, as, going back to my point - this exam is limited to the BNF, and a few common OTC resources. By further education, I am referring to papers, and studies, new evidences on practice. The Post Graduate Diploma in Pharmacy Practice that is offered as an option by my trust allows me to enhance my knowledge and improve my practice on the job - i.e. with ward visits and feedback from colleagues (pharmacists and other HCP).

@Naimah - I don't think it's helpful to compare ourselves with other professions with different structures of initial education and training. Yes it's unfair - but medics and nurses don't have a pre-reg year after they graduate from university and then do a one whole year of placement, where quality is variable.

After reviewing the point that Ruby made about the exam not reflecting practise. The exam tests your ability to assess how you can assimilate and interpret the information you have in front of you to arrive at the most appropriate answer. It is not a regurgitation of the BNF, a comment which has been made many many many times, and those who believe that are incorrect in their comment due to the reason I have already given. I hear what you are saying about how the information may not be the most up to date but that is not the point of the examination.

I am a resister waiting to write the exams if it happens.. I have been working as a locum dispenser now and I have worked with a lot of pro reg pharmacists. And some of them are even better than some pharmacists I have worked with. So can they be defined by an assessment. They are working hard through a pandemic. I think there should be another way of assessing these prov reg. I don’t think Gphc will cancel the assessment for us resitters. 

Ruby, you have made a very interesting point about "further education" but I believe you have misguided yourself on this point. The point is that the prepping should be done in your own time and you will learn things during your prepping that you may have missed so it is, essentially, further education.

In September, the GPhC encouraged pre-regs and prov-regs to look at “the example questions and learning points from previous sittings” as the topics in the exam and the standards required to pass will remain the same.

@Ruby said that there are some clinical aspects of the BNF that are not really used in practice but the exam doesn't reflect that. 

Perhaps this year's exam could take this factor into consideration? And the GPhC could ask candidates to focus on a restricted amount of topics, considering how busy most candidates currently are with work commitments. Also, revising for an exam in the middle of a pandemic, potentially after a long day at work, doesn't sound so easy to me... 

Or would testing candidates or a smaller number of topics compromise patient safety?

I just wish all pharmacists have to take the assessment periodically and we will see how many will pass. 

Nahim, I agree, I have even witnessed a colleague who was bullied by a tutor, but I would use the pandemic as an opportunity to make changes to the system, not to stick to old rules and exam set from a very long time ago. 

I have personally had a great tutor who was always there for me. However, the idea of the exam was always causing me so much pressure. The whole point of the pre-reg year is to learn from the practice as we have spent 4 years learning what the GPhC wanted us to learn in our pharmacy practice modules. All pre-regs do is worry about the exam, their whole focus is - what do I need to do to pass this exam, and this defeats the point of the training year. 

If we were to find a way to  do mini-assessments throughout the  year, to make  sure that people are on track  this way the workload would be divided, there wouldn't be too much pressure on one exam/one day only - and the pre-regs will learn much more from their day to day practice. 

I have even met a pharmacist who registered the year prior to the enforcement of the exam, and ever since she said how negatively it has affected the pre-regs and how much their learning from practice, along with their mental health is affected. 

We've got 10 minutes left of the formal debate, guys. Thanks so much for such a measured, intelligent debate so far. We'll be logging off at 8pm but feel free to stick around and debate or chat for as long as you like.

I agree with Ruby, all that we focus on is passing the exams at all cost with actually concentrating on the skills acquired in practice. I am hoping the introduction of the foundation course will help focus more on practical skill rather than achieving exams skills 

After looking through Twitter, Greg Lawton posted this on 27 September 2020 after fact checking the argument that other professions has cancelled their examinations:

"Greg Lawton @thisislawton · 27 Sep 19. It is inaccurate to say that other professions have sat exams. A. My understanding of the regulatory requirements for UK and overseas doctors, dentists, nurses, solicitors and barristers is that the usual exams will remain a requirement before full/permanent registration." I have posted the tweet as it originally appeared.

Paul, I believe we all have weaknesses and gaps in our knowledge, with an exam or without. I have even spoken to currently registered pharmacists - some who have registered a year or 2 ago, I have asked them some questions (that are exam questions, based on the practice questions I do and miss/keep missing) and they all acknowledge that they have studied it for the exam and they no longer remember the information/the topic. 

Being realistic, if you do not use it, you loose it. I have met so many specialist pharmacists that know so much about their area of expertise and less about other areas. That is completely normal, we have also been taught for so long how to develop and use our professional judgement, if I do not know something, I am not going to risk a) a patient's safety, b) my registration just because I did an exam x amount of years ago that covered the topic. 

By further education, I meant areas of interest, because again, we are all different and we are all interested by different topics, I might find that I am strong/I enjoy a particular topic/area of expertise and I want to pursue it. However, by having to study for other topics that I have already covered in my university and I know where to find information about, to pass the exam is to me a hindrance of my professional career. 

As the role of Pharmacist continues to evolve, the need for clinical understanding and interpretation of reference sources and information is as important as ever. Pharmacists are currently showcasing theit expertise they have to offer in both primary and secondary care and the clinical aspect of the exam is essential in maintaining that minimum standard for all those registering.

Prov-regs are not mandated to accept employed positions as temporary pharmacists and other work may be available in alternative industries that allow the ability to study alongside whilst maintaining essential income. Finally for those who believe they have demonstrated what has been required, there should be no hesitation in attempting the exam.

Agree with @samuel and some other comments above, GPhC still following outdated exam format, hospital have such advance EPR system and can rule out many clinical issue before reach to us even in community as well like common interaction. People should able to know how to interpret information and take appropriate action rather then sticking to tick box exam. This year they have perfect chance to change format and focus more on current reality.

Imagine sitting on an aeroplane knowing the pilot hasn’t even passed an exam 👀✈️ 

I appreciate the pressure during the pandemic and sympathise with that wholly, but the pressure of an impending exam is something everyone feels. I felt it before my pre-reg exam, I'm sure most did, it's hardly an excuse to cancel the exam.

The exam has been delayed for quite some time now and Prov-Regs should have initially started preparing for the exam prior to the news that it was going to be postponed... So they've got the slight advantage of more time and more practice (again not saying you guys haven't had it tough over the last few months with COVID). 

Working and studying is something all of us have had to go through, and will continue to go through to further our education, it is an everlearning degree, you can't just stop working every time you want to advance your career or not advance your career due to work.

I believe Prov-Regs will be fine in this exam. As many have stated they have been working throughout, have provided to be exceptional pharmacists & that the exam is just regurgitation of the BNF (not sure I agree), but if this is the case- The assessment should be a breeze for you and completing it would “give the public the assurance it deserves”.

As others have said on other platforms, it is a benchmark, a bare minimum to prove you are safe and fit to practise. Everyone needs to sit it at some point, the purpose of the register and the assessment is to deem individuals fit to practise and provide a means of ensuring patient safety. The registration exam serves to protect, honour and safeguard the profession and the professionals.

You have at least 2.5 months to prep for it, so I suggest to use this time to rest a bit, start prepping so the revision can be done at a steady manageable pace and don't fret. If you've been working as a Prov-Reg you've clearly been deemed as fit to practise temporarily, so you have the skills. Good luck!

There seems to be a misconception that the pre-reg exam is BNF regurgitation exercise. This certainly isn't the case, it is predominantly closed book aside from a resource pack containing SmPCs, a medication chart, BNF extracts (to enable calculation of body-weight doses, bioequivalent dose conversion etc) and diagrams and photographs.

It is about application of knowledge and understanding under pressure (timed conditions). You are assessed on medicines law, interpreting clinical information, ability to assimilate SmPCs and BNF monographs and thus the ability to make clinical decisions under the context of time pressure.

Pharmacy PMR systems provide a cushion of clinical safety by providing electronic clinical decision suppport systems by way of alerts, interactions, allergies, cautions, warnings, etc. A lot of the time it is these clinical systems that flag serious issues such as high severity drug interactions, similar drug alerts or drug allergy alerts, often requiring additional input from the responsible pharmacist to override them.

Is Lorazepam allowed on an FP10MDA? Can dentists prescribe Codeine on an NHS rx? Can Fentanyl be given to an opioid naive patient? In many cases the PMR will disallow or flag these issues and so in practice we needn't worry about it. Yet as Pharmacists we are supposed to be able to know this and be able to capture all clinical and legal issues without relying on the PMR. The pre-reg exam is that medium that allows you to show some of this proficiency of knowledge and ability to comprehend multitudes of information at an appropriate pace and make a safe and effective clinical decisions.

You all know the importance of calculations in pharmacy and don't need me to remind you of the Peppermint Water case where a new-born baby died as a result of calculation error. Murphy's Law; anything that can go wrong, will go wrong. Thus rightly so, there is a 2 hour calculations paper that needs to be passed. I would hope there is no counter argument to the importance of that.

I’m late to the debate again! Interesting opinion and views. I think the exam process and content does need reviewing to make it fit for purpose for 2020 and beyond. And some people have mentioned continuous assessment throughout the year/modules to break it down and reduce the pressure on one day. I think there’s something in that. I do agree with some form of examination remaining to assure the public.

@Paul, I think you’re spot on with what you said at the very beginning about the exam fulfilling all of GPhC’s criterias.

I know it’s stressful, especially for this year’s cohorts but that’s the way it is. I vote that an exam of sorts should remain.

Besides, we went through it and we’re ok! Not to mention all those who didn’t make it throughout the years, would they be safe to practice if an exam didn’t exist? I’d be uncormfortable with that. Surely not all pro-regs would pass said exam, it tends to filter out those who aren’t fully competent.100% pass rate is highly unlikely.

@Mitesh Patel Nicely said, and completely agree with your points. I was thinking about precisely that case with regards to calculations! 

To make myself clearer: 

I do not think the exam ensures/guarantees safety of the public, simplest proof - mistakes still happen. I think there needs to be a move to how we deal with mistakes to learn from them, this is of course something to focus on from now on, now that there is an opportunity to do some changes.

As Samuel said, my whole point is, I am unsure if all currently registered pharmacists will pass the exam it if they take it, not because they are unsafe, but because of all the reasons I have mentioned before of specialisation and career progression. 

I am happy to see many of you believe that the whole pre-reg year/examination style needs reviewing. I am possibly also wondering why this was not brought up before, but I hope that we will all take part in improving the situation for the next cohort. 

The point isn't to make it 'easier' and therefore unsafe - the point is to help ensure that the mental health of our professionals are preserved and that they do not go through a horrible time because a) of fear of their tutors, b) of an exam that is going to determine whether their past 5 years have gone to waste or not. It is important to bear in mind that we are better, when we are stronger and healthier. 

@Ruby. The exam is not there to ensure or guarantee public safety. The exam is there, in part, to prevent people coming onto the register who are not competent to do so so therefore this satisfies the public protection limb. Although I agree that the mental health of anybody is extremely important, this is not the most important aspect of going to a new system of assessment. Any method of assessment must demonstrate that it can be effectively used to objectively assess an individuals performance which will allow them to practise to a minimum standard from the day they are enrolled. 

I do hear what you are saying about the exam being viewed as a cliff edge but if an individual fails the exam at any point, it is not the end of the world. To quote Cat Stevens from the song "Father and Son" - But take your time, think a lot, why, think of everything you've got. For you will still be here tomorrow but your dreams may not

If any pharmacy student, pre reg, prov reg are registrant is having an extremely tough time, contact Danielle and the team at Pharmacist Support on 0808 168 2233. I have worked closely with them for quite a few years and the team are fantastic.  

@Ruby improvements to the exam are constantly highlighted by every cohort, and I agree, you should highlight it again, but the exam shouldn't be scrapped. 

Learning from mistakes is well and good, but we should aim to prevent the occurrence of mistakes in the first instance, not let the professionals run around making mistakes and then retrospectively learning from them, hence the need for the baseline competency assessments.

If you think currently registered pharmacists wouldn't pass the exam and that specialist pharmacists lose knowledge, you circle back to the debate about regular assessments that the GPhC considered. Would you rather do one baseline assessment, be deemed fit to practise and get on the register and then prove continual learning and competency through CPDs and other methods OR have all pharmacists sit regular assessments every 2 or so years (for the rest of your working life)? Which would be more stressful in your eyes?

I had a really tough tutor, yelled, rude, left before my final sign off, made me do a minimum 3-5 evidences per performance standards (including CPDs for each), only signed off 10 competency, then said there was too much too read before she left... eventually the E&T lead made me map out every one and pick out the best + fewest number of competencies for her to read so they could read and sign me off.

I get the pressures of a tough pre-reg year, it sucks, but again this is you protect you and the public.

My last question

what about those pharmacists that never sat the assessment and have been on the register since. When the assessment wasn’t a criteria to be registered.  Are they a danger to public safety. 

Regardless Prov-Regs' should start prepping for the exam and their employers/supervisors need to ensure they are appropriately supported and allowed adequate time off to prior to the exam to prepare, especially because of the exceptional circumstances you've been through! 

Such an interesting debate and here I am very late to it. Just a few not entirely joined up points:

 I am old enough to have joined the register before such a thing as the pre-reg exam existed! With hindsight I wish there had been one, on the other hand it doesn’t seem to have done me any harm in the long run. I would say it’s all about attitude to learning once on the register. 

probably a good analogy is the driving test. Passing really is important, both theory and practical. How would we feel if that had been abandoned & folk were allowed on the road without having passed?

in my experience of newly qualified pharmacists it only takes a few days of me working with them to know if they passed their pre-reg exam first time. I find there are those who breeze through demonstrating their competence and are totally ready to practice and those who manage to scrape through on a second or third attempt by knowledge cramming for the day and a lot of markers in their BNF but ultimately, in my experience lack the soft skills and good professional decision making capabilities of their first time colleagues. This may be controversial for me to say and I’m usually quieter because I don’t have a ready alternative solution to voice. Here though. More experience pre-exam should only be grist to the mill and make passing the exam much easier in the long run.