Getting More Familiar with the Pharm
An Interview with Pat Clinton and Teri Moser Woo

It takes a lot of work to create each new Pediatric Pharmacology SAE, and we want every CPNP® to feel comfortable with the goals of this self-paced learning activity. We'd also like to share some insight on what it takes to make this exercise possible. The Pharm SAE was launched in 2003, so we talked to Pat Clinton (pictured left) and Teri Moser Woo (pictured right), two committee members who have been involved since the Pharm SAE's beginning, to shed new light on this unique SAE.

First off, please share with us the basic process as a question submitted by an item writer becomes a final question that appears in the test item booklet.

Teri: The items that are submitted by an item writer are reviewed by the committee for content and clarity of the question. There is a test blueprint, so an item may be good but not used due to having too many questions in that content area. All good questions are saved for future exams.

After the question goes through the committee and we decide to include it in the exam, there is a final editing by both the CPNP® staff member and an editor to make sure the question and resources are accurate. We want to make sure that if an item writer states they got the info in the question from a certain resource, that the information is actually there. I was the editor for this past exam and looked up the answers for every item in the exam to ensure accuracy.

Pat: The committee actively seeks item writers for questions. Writing good questions is difficult and time consuming. Virtually every question, whether from novice writers or experienced writers, is reworked to some degree. Committee members look at questions that have been submitted and screen for a number of things. This might include level of difficulty, application to practice, relevance, currency and of course accuracy. Cathy Haut, PNCB's Deputy Director, is an additional screen for content, accuracy and currency. After this initial screen the questions are reviewed by the entire committee composed of NPs, PharmDs and MDs. All weigh in and make sure the question and the answers are defensible and reflect best practice. So the question an individual submitted may look very different from the original version. Questions that don't meet some or all of the criteria may be reworked or possibly are a better fit for a different exam.

For all questions clarity and plausibility is important. Sometimes coming up with foils that are possible but not correct is the most difficult part of the process. There are lots of tips to writing questions such as answer choices should all have roughly the same length, should be gender neutral, avoid "all or none" statements, be clear and brief, and of course sensitive to cultural issues. Finally, I think we all ask ourselves: "Is this question just trying to be tricky or obscure, or is there a reason why attention to a particular aspect of how the drug works is important for the person to remember when prescribing the drug?"

Some CPNPs® may feel a particular question is too obscure to have any relevance. Can you share your thoughts on how things like geographic location and preferences factor into the choices you make in creating and selecting questions?

Pat: We use a test blueprint to make sure we are covering relevant content and show diversity in culture (where appropriate), age, drug classes, etc. Some committee members may have particular expertise in specific areas, which is helpful in formulating questions. However, we try to remember that this is a primary care focused pharmacology assessment. But it is important to remember that children in primary care may have significant medical histories with treatments and medications prescribed by specialists. It is important for the PC provider to know those drugs, the side effects and possible interactions with other drugs such as antibiotics, birth control, etc. Prescribing preferences do vary by geography, in part dictated by where the provider was educated and what the preferences were in a particular practice or hospital.

Obscurity is not the goal but the questions have to be relevant to primary care in some way and challenging enough to make the exam a real learning experience.

Teri: As Pat mentioned, we are finding that PNPs often care for children whose chronic illness is managed by a specialist. If a child with a seizure disorder presents with pneumonia or otitis media, the PNP needs to understand the interactions between the seizure medications and any antibiotic they are choosing to treat the pneumonia. We don't expect a PNP to be the primary prescriber of the seizure medication, just to understand the pharmacology of the medication so they can appropriately care for the minor acute care need.

The Pediatric Dosage Handbook is the accompanying reference for this SAE, and we encourage CPNPs® to get to know this wonderful book, with all of its text, tables, and charts. How do you feel about the Pediatric Dosage Handbook as a resource?

Pat: The PDH provides accurate information in one handy place. Most questions can be answered using this alone.

Teri: I love it! I find it very helpful and clear. It is up to date with newer knowledge about drug-drug interactions due to CYP 450 metabolism and has referencing for dosing that is off-label. Plus it's small enough to carry around.

In addition to the Pediatric Dosage Handbook, some answers can be found in a variety of resources... And not all answers are journal-specific. When a CPNP® calls us about difficulty in finding an answer, we encourage them to use their hospital library, but not all CPNPs® have access to one. What recourse would you suggest to those struggling to find sources to address a particular item?

Pat: There are a variety of online pharm resources that can be used. A good place to start is the FDA site (http://www.fda.gov/default.htm). I would also suggest asking a PharmD if they are really stumped. Hopefully there are not too many of those types of questions that can't be answered with the resources at hand. We hope the exam reflects current practice and guidelines that are readily available to everyone.

Teri: The internet. Almost every household has a computer. Most schools allow their alums access to their medical library. I suggest that PNPs contact the library of the university where they graduated from and see what remote access they have available to alumni. Once you get used to remotely accessing your medical library, you won't want to drive there anymore!

This SAE is compiled using a content outline that reflects all body systems and the processes of prescribing and monitoring many different drugs, as well as educating others about their use. What do you feel is the biggest challenge in making the exercise fit the content outline?

Teri: We sometimes get too many from one content area or we run out of a variety of questions for a body system. Sometimes we get lots of asthma questions and few questions that involve other respiratory problems such as allergies. Plus you can only have so many asthma questions before it becomes repetitive.

Pat: Making them relevant to practice, challenging enough and interesting, avoiding repetition.

Pharmacology changes. Therapeutic modalities change. The PNCB's ultimate goal for the SAE is to update the knowledge base of every CPNP® and to help them learn more for practice purposes. If a CPNP® comes away with only one concept from taking the Pharm SAE, what would you hope this would be?

Pat: Prescribing is a privilege and requires constant attention to detail and currency in practice. A prescriber has a huge job of keeping up with the literature. That is why attending conferences and attending sessions with pharm content is critical. Read the professional journals and ask questions. Most important: Always look up drugs, double check for appropriate therapeutic application and dosing, and listen to your patients when they report reactions to drugs or have questions themselves.

Teri: Developmental pharmacology and the FDA labeling changes. These are two, but both are important... Developmental pharmacology is the concept that there are developmental changes in how children process different medications. For example, kidneys don't reach full maturity until somewhere between 7 and 12 months, so we don't prescribe ibuprofen, a renally excreted drug, routinely to children younger than 6 months.

The FDA has mandated pediatric studies of drugs that are already on the market to determine safety and effectiveness in children. We have been prescribing off-label to children for years. These studies are allowing accurate labeling of medications based on evidence. I get frustrated to see that PNPs are not following the new labeling guidelines and say "we have been prescribing that for years." Just because we have done it for years, doesn't mean it is safe OR effective. Keeping current on labeling changes is what is safest for our pediatric patients.

Thank you both so much for sharing a wealth of behind-the-scenes information with our CPNPs®! Your time, expertise, and enthusiasm continue to energize the Pharm SAE Committee and your fellow members, and we sincerely appreciate your dedication!

If you're a CPNP® who chooses the Pharm SAE this year, you now know the efforts that go into this exercise. Would you like to be a part of this process? We're always seeking external item writers. If you'd like to write for this or any other SAE, please contact Janine Rauscher, Director of Volunteer Services, at jrauscher@pncb.org.

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