This will be brief. CCNEPal teaches a version of Advanced Cardiac Life Support to nurses and doctors in Nepal. Since inception in 2011 we have trained 4,500 nurses and doctors. ( yes, it’s a large number, hard to believe). We usually spend about eight to ten weeks in Nepal in summertime.
Nothing is ever official until I buy my airline ticket in March or April. But we are beginning to think about activities.
There are certain host agencies and schools we always work with, but each summer we are willing to go to new places to share our knowledge and to consult with the local professionals as to how to do critical care. We tend to work more in the Terai these days.
If you are interested to host us, browse this blog and find previous entries that describe what we need in order to run a successful training. Then send an email to email@example.com
This is a book review of The Vagina Bible, which finally hit bookstores only a couple of days ago. I posted it on another blgo then figured I would crosspost here.
The executive summary? Get it. Read it. Share it. If you want more details, step over the line.
Who is Jen Gunter, MD?
Jen Gunter MD practices medicine in the Bay Area of California and is a fully Board-Certified OBGYN in both Canada and the USA. For those who do not follow medical credentialling, “board certified” is the gold stamp of approval in terms of clinical expertise. Her official title would be “Jen Gunter MD, FRCS(C), FACOG, DABPM, ABPMR (pain). She explains the meaning of the string of initials if you visit the “about” page of her website. But Dr. Gunter is very approachable and informal and a tad irreverent when she starts talking about her passion — women’s health (which is also “human health” if you think about it).
Dr Gunter’s motto for her Twitter feed has been “come for the sex, stay for the science; come for the science, stay for the sex.” which is apt. Also, “wielding the lasso of truth.”
She is impeccably grounded in the research to support a sound approach to gynecology care, and yet also has a sense of humor that is utterly delightful to a curmudgeon such as myself. She is is a master of the 140-character takedown of those foolish enough to dispute her expertise.
That is what I have decided to name a collective of mansplainers. A murder of crows, a parliament of owls, a rash of mansplainers. In medicine a rash can be a mild annoyance that goes away and never returns. A rash can also portend a serious medical condition, even something malignant.
There have always been a few men here and there explaining vaginas to me. I have suffered fools eager to use pickup lines about being an amateur gynecologist, detailing their imagined superior knowledge of female anatomy and physiology. Men who think sitting beside them at a bar and smiling — because if you don’t smile, you get told to smile — is an invitation to tell you how they will make you scream and moan.
I was already hooked on her writing, but this made me howl with delight. The piece was a manifesto of sorts, and Dr Gunter gained a following that went beyond a mere cult, into the mainstream. Her subsequent skewering of myths and misconceptions promoted by the women’s wellness industry has attained legendary status, especially with her science-based analysis of false claims by GOOP magazine, over such issues as the use of Jade Eggs. These days I don’t think anybody can read the name ‘Gwenyth Paltrow” without also thinking of Dr Gunter and the way her lasso reeled GOOP in.
The dedication says:
For Every Woman Who has Been Told — Usually by Some Dude —
that she is too wet, too dry, too gross, too loose,
too tight, too bloody, or too smelly.
This book is for you.
The chapters are logical, first starting off with accurate medical information as to anatomy, then going in to childbirth. Then she gives practical advice on such things as lube, underwear, menstrual hygiene, sexually-transmitted diseases, and common complaints or symptoms that bring a woman to a gynecologist for examination. Throughout, she maintains a pro-woman attitude that would make me want to tell me daughters to make an appointment.
In greater context, this book is the next logical heiress to Our Bodies, Ourselves, the famous book by the Boston Women’s Health Collective that championed the revolution toward woman-friendly non-patriarchical women’s health in the 1960s and 1970s. That book went through successive editions that made it larger and larger; the most recent updating was in 2011. My wife and I had a copy of OBOS which we left laying around the house for our daughters to read. Gunter’s book is very readable and rivals the colloquial style of Everything You Wanted to Know About Sex ( but were afraid to ask) by David Rosen, MD, another pop book from the 1960s that was a #1 best-seller of the New York Times when it came out ( and later made into a movie by Woody Allen). (it seems to be out of print).
I would be remiss to omit Dr. Gunter’s unerring and consistent defense of a woman’s right to choose; her insistence on framing the abortion debate in medical terms including calling out the lies about “late term abortion” and “infanticide; ” and fighting back against other attempts by radical pro-life extremists to fan the flames of emotion rather than appealing to rational science. I don’t follow the pro-life extremists on Twitter but they seem to flock around Dr. Gunter like moths to a flame. She seems to be a lightning rod for pro-life weirdos and yet she supplies excellent talking points on the front lines of compassionate gyn care. The Vagina Bible is not, however, a polemic book carrying a radical torch. Dr Gunter stays very carefully on the side of science-based advice in all areas it seems to me.
Barnes and Noble
I got my copy in the Women’s Health section of Barnes and Noble here in Tampa. Why it was not yet stacked on a table in a more prominent area of the bookstore was actually a mystery to me, since the topic is of wide interest and the book is well written and factual. Maybe there are just not that many nonfiction best sellers these days. Still and all,this would be a great beach read, the kind of book you could enjoy by just going to a random page.
I should say, this past week there has been a bit of a controversy on Twitter since her publisher wanted to run a series of Twitter ads with the book title but was somehow blocked by Twitter due to the prominence of the word “Vagina.” For those of us who have been following the good doctor, this has been a strange twist. We have a situation where Alex Jones and his ilk can promote lies about such things as Sandy Hook; where people use not just the f-word but also the c-word; and of course a President who lies and also shares top secret national security items that put American lives at risk; and yet — a book written by an MD in which the title describes the subject is somehow off limits? Get real.
Amazon Book Reviews
I shared this review on Amazon, and I was at first surprised to read that there was a one-star review posted by an MD at that site. Turns out, the MD in question has her own nickname – “The Love Doctor” and in Austin Texas she runs the sort of bespoke clinic that promotes just about all the trendy treatment modalities that Dr Gunter is advising against. So – I expect there to be a backlash from proponents of the “Vaginal Shaming Industry” that Dr Gunter is informing us about.
I give this book an A plus for readability, accuracy and reliability.
I am not in any way associated with Dr Gunter, or her publisher. I have not received any compensation for this glowing review in any way. I paid for me own copy and I had to wait for it like everyone else!
I am back in USA this week, and next week I resume teaching at a nursing college in Tampa, Florida. The flight from Nepal to USA was uneventful but long. Oh wait – I lost my wallet and one of my bags got lost – but overall it was okay. I would recommend Quatar Airlines to anybody.
I was in Nepal eighty-two days. I taught thirteen sessions of my course, and awarded 317 certificates to nurses and doctors. This was fewer sessions and certificates than past summers where I tended to teach about 24 sessions and got close to 600 certificates each time. I had a number of requests to teach additional sessions that I was not able to fulfill, due to travel requirements or the heat.
Most of the sessions were at College of Medical Sciences in Bharatpur. This host agency has an airconditioned classroom which has ample space and they supported conditions that made it easy to feel good about the quality of learning we could provide. My partners there have known me since 2011. They provide fooding and lodging (with aircon!) and they were always upbeat. As in past summers, I note that the students at CoMS are more often from the Terai and indeed to complete their government service in Terai; this is important because Terai needs to work more on outcomes for health than other regions. I think I could walk into any number of subsidiary hospitals in Terai and be greeted by a nurse or doctor who took my course at CoMS. Like all good Universities, CoMS serves as a knowledge node from which expertise billows out.
CoMS was kind enough to allow me to teach a session to nurses and faculty of NPI Hospital and NPI college of nursing. I had previously taught a session at the NPI hospital but in an area that lacked aircon.
I knew it would be hot, but not this hot. My problem is, I can only go to Nepal in summer due to my teaching job. I was asked to teach in other Terai locations, but declined to do so unless there was air con. Also, my highly- anticipated trip to Nepalgunj was postponed indefinitely due to heat, then flooding.
I taught only one session in Kathmandu, at Bir College of Nursing. The audience was BNS students. These persons are returning for a Bechelor’s Degree. The pathway for them is get their PCL, then work two years and return to school. Most of this group were working in the system of government hospitals, and one of the priorities of the Ministry of health is for the BNS students to focus on critical care skills. So the group was an ideal target audience for me. They were so much fun to work with. I returned there a week later for a daylong session on ecg reading, something I don’t normally do.
Other hosts in Kathmandu
I can legally teach my sessions in Kathmandu because I have an RN license in Nepal. However, there were two other host agencies operated by the government that originally wanted me to teach, then requested me to show a letter from the Ministry of Health to authorize my teaching. This is also a pathway to “legally” teaching, but one which I was told by the Nepal Nursing Council that was not needed by me. So the first plans went nowhere. I am exploring the idea of taking steps to get such authorization from the MoH for next year. There are about thirty hospitals int eh government system trying to upgrade their critical care skills, and I am thinking this might be a good focus.
I returned to Terai for one session, at Bharatpur Hospital. The roster there also included faculty from NPI, and from Balkumari and from Maya Devi College, in addition to the nurse who serves as Regional Burn Coordinator.
My daughter the tourist
The last two weeks of the summer were devoted to tourist activities. My older daughter finally visited me in Nepal and we had fun. She later said how much she loved the people and culture here and that “it was the trip of a lifetime.”
The itinerary included three days in Chitwan seeing wildlife and interacting with elephants.
She also got a kurtha jangrawal at a place in Indra Chowk, and went on a yoga retreat.
It was good to stop and smell the incense.
Airway Management Trainer
How could I forget! CCNEPal organized a crowdfunding campaign to donate one of these to CoMS. We made a handover on July 25th.
Time to reflect
I now have six or eight months to think about how CCNEPal can help advance the practice of critical care in Nepal. I will be thinking of ways to move the project forward in future years. I expect to decide about the 2020 trip in March or April, then send out an announcement as to available time slots and sessions in April or May.
Naturally the general public needs to learn about the best way to proceed and that is a noble goal to guide the Nepali press in a democracy. All Nepali families wish to support the success of their younger members, and many young persons see the possession of a nursing degree as a ticket to employment in a Nepali hospital or as a vehicle to go abroad and see the world while sending remittance home. They can do this while serving humanity. There is nothing wrong with these aspirations.
नर्सिङ शिक्षामा मनपरी : यी ९३ वटा कलेजका आफ्नै अस्पताल छैनन्
स्वास्थ्य, शिक्षा मन्त्रालय, काउन्सिल, सिटिइभिटी र विश्वविद्यालयकै कर्मचारीको मिलेमतो
This is devoted to a discussion of how many of the nursing colleges in Nepal are associated with a hospital. Oh My God! Ninety three are NOT! Now, the fact is, most major hospitals in Nepal operate their own nursing college in the first place. But there are colleges that would be called “free-standing” if they were located in the USA. In fact, the vast majority of nursing colleges in the USA are “free-standing” and it does not hurt the nursing education offered to students in USA.
The reader is invited to look at the Swasthya Kahbar article. I have written a long comment at the bottom, which I will repeat here, edited to improve formatting:
Here is my specific reply to the article in Swasthya Khabar:
(begin quote) This article has strayed from the real issues in nursing education planning. The direction of the article is to accuse all the 93 nursing colleges of breaking the law and suggesting that these colleges need to be penalized. ( and the list of offenders is included, implying that the leaders lack integrity. Are they trying to shame the colleges or would they do better to find a solution?) That is not the way to proceed.
First, it is simply ridiculous to suggest that any nursing college now open their very own hospital with all that it entails. Will the Campus Chief of each nursing college suddenly become a hospital director, employing Medical Officers and Surgeons and operating an Emergency Room and Operating Theater? That idea in itself is ridiculous – of course not. We already have a situation where any group of doctors that can pool their money to build a “hospital” can do so, without any real planning or oversight by any level of government. Why adopt a policy that requires more building construction without consideration of hospitals that already exist nearby?
In USA, it is the general practice for colleges of nursing to operate independently from owning their own hospital, and this would be okay for Nepal too. Of course, in USA each school is required to have an arrangement with the nearby hospitals to allow their students to go there to learn how to take care of patients. Nepal would do well to adopt that approach. A hospital needs nurses, but staff nurses are expensive because to be paid, so it is typical for many of the hospitals in Nepal to start their own nursing college. The labor of the students substitutes for the paid labor of staff nurses. This is a lesson in “economics 101.” In USA these agreements for students to serve at hospitals not owned by their school are called ” affiliation agreements” and the existence of such an agreement should be the proper subject of investigative journalism, not whether the college owns their own hospital.
A better way to explore the issues in nursing education
As for me, it’s true that I am a videshi, but I write a lot about nursing education in Nepal since twelve years. You are invited to read my blog, http://www.joeniemczura.wordpress.com . Now, there are areas in which nursing education in Nepal can improve, but this article is simply not helpful in describing what those areas may be. Anybody who wishes to discuss this with me is invited to find my blog and make a comment. (end quote)
Does that make any sense to you?
I do think the concept of affiliation agreements is already part of the system being described, but there seems to be selective choice to focus on some other idea in the current situation, and I think the focus needs to be maintained on the quality of education, not the presence or absence of a shiny new building that lacks a reason to serve the public.
Over the past eleven years I have watched others come to Nepal to try to teach something, and not succeed. Maybe they don’t assess the audience before preparing teaching methods, or maybe they overestimate the English language comprehension, or some other unexpected issue. There is a long list of pitfalls. We assume an expert clinician somehow knows how to teach.
This is not limited to westerners trying to teach. I recently spoke with a Nepali doctor who decided to teach the nursing staff a new skill by assigning all of them to read a certain book in English, after which he would administer a written test. Yes, that might have worked in Medical College, but it’s not the best strategy for nurses.
I am not an English teacher, I don’t teach English per se. I teach content related to cardiac resuscitation and nursing, to classrooms of people who can speak some English. The people in my class sometimes possess excellent English proficiency and sometimes very little at all. It is not my goal to make them speak English, but the goal is to help them do better resuscitation using critical care skills.
Having said the above, I do find that my background in teaching ESL students is very handy. Look at it this way: I
The View from the front of the classroom.
n Nepal I am always teaching an entire class of ESL students. Many of them already speak Nepali, and Hindi, and perhaps a third language such as Newari or Maithili, prior to taking up English.
“You can be excellent at this even if you speak no English”
My own list:
start off by going around the room to determine the English language level of each person present.
speak in English using the grammatical structure of the local language especially if it is an Asian language.
learn a few phrases in the local language and especially learn the top ten body language gestures used by the host culture.
don’t use PowerPoint but do use a Whiteboard
don’t use vocabulary words longer than two syllables
stop and define specialized words
don’t speak more than three sentences at a time
don’t bring a pile of handouts
do have a FaceBook page for the class that helps people learn in advance what will happen in class.
build in class activities for small group discussion about the content in the local language
think of an exercise or game to accompany each little segment of learning.
assign the better speakers to buddy up with those who have less comprehension
For nurses who teach overseas, I think there is some expectation that somehow they will return a wiser, more well-rounded person with deeper understanding of the human condition and a more articulate way of expressing the universal truths of life on earth. This idea of examining your own assumptions of teaching and learning is a prime vehicle for that realm of self-discovery.
failure rate on June 2019 Nursing License Exam
The recent pass rate for the Nursing License Exam in Nepal was 35% announced in July. In other words, 65% of the examinees failed the exam. The exam is a two-and-a-half-hour paper and pencil test with multiple choice questions in English, and while the scores are not released, the test-take must answer at least 50% of questions correctly. A sample of typical questions on the exam can be found here: https://www.slideshare.net/rsmehta/nepal-nursing-council-licencing-exam-mcqs-sample These sample questions were published around the time of the 2012 exam.
The vast majority of women enroll in Proficiency Level Certificate (PCL) programs, and there are eighty such around the country. You can enroll in PCL even if you don’t pass the SLC exam. The SLC is referred to as “the iron gate” and these days about 20% do not pass. This is better than it used to be. In other words, after passing tenth grade at the age of sixteen a girl can enroll in nursing school here. She could graduate at the age of nineteen.
If the nursing exam was constructed
by the same people who were in charge of the old SLC exam, that is a problem.
The SLC mindset was to disqualify everyone, not to really measure anything. Any
good teacher soon learns that it is easy to construct an exam that nobody can
pass, not even themselves.
During the time of the Constituent
Assembly, the Nursing Council attempted to institute a system of regulating the
establishment of new nursing programs, but they were over-ruled in a dramatic
fashion when a different political party came to power. The government took
control of new nursing programs and loosened the requirements to start a PCL
program. At the time, the Nepal Nursing Council leaders were replaced. There
were rumors that money changed hands.
Boom a Factor
Now, to be fair, the government had
a problem at that time, which was how to provide a career path (other than
homemaking or shopkeeping) for young women, since there are so many young
persons in Nepal. There has been a “baby boom” and to create the
future, jobs must be created. PCL nursing was proposed as one avenue to prepare
girls from the village for hospital work. Often, the government advisors did
not really have an understanding as to the responsibilities of nurses and the
knowledge base required. In about 2013, I recall attending a lunch with an
American anthropologist and some women’s advocates who were in favor of
relaxing the standards of nursing education mainly to give employment, heedless
of any academic requirements. They wanted to create lower levels of health
workers that would not be as stringent as nursing education. They failed to see
that this was a step backwards, not forwards.
The high failure rate of the licensure exam is not a new thing. In 2014, the first year it was implemented, there was an outcry due to the failure rate. At that time, I wrote in my blog that I believed the minimum education prior to admission to nursing school should be “SLC plus two” – meaning that an additional two years of science education should be taken, and thereby increasing the age at which a woman is admitted to nursing school, to eighteen with a resulting higher maturity level. At the time, B SC programs were just coming into existence in Nepal. There has always been a paradox in B Sc nursing education. Nurses trained at the B Sc level are less likely to be subservient to doctors and are trained to speak up on behalf of the patient. At many hospitals, doctors perceived them as a threat and resisted hiring B Sc nurses since they were more likely to advocate for holding the doctors to a higher standard. In those days fewer women attended MBBS programs. B Sc education needs to be covered in a separate blog.
I have written about nursing and
nursing education issues in Nepal since 2011 on this very blog, and you can
browse the 270 previous entries to see the general focus of my work. I first
came to Nepal in 2007 to teach at Tansen Nursing School ,a PCL program in Palpa
There has not always been a licensing exam for nurses in Nepal. This was started around 2012, partly because the International Council of Nurses pressured the Nepali government to comply with international standards for nursing education so as to promote the portability of a nursing education across national borders. In other words, without adequate credentialling, a nurse who moved to another country from Nepal would be required to take their nursing education all over again from the beginning before becoming eligible for licensure in a new country.
At the PCL level it is not uncommon
for the nursing faculty to only have a PCL degree themselves and be only a few
years older than the students. There are fewer role models. This has been
changing but not quickly enough.
Language to use for exam?
Now, the language of instruction and
the language of the textbooks is an issue. Most textbooks are written in
English, and supposedly the language of instruction in nursing is English. The
licensure exam is in English. This presents a variety of problems. First, even
if the textbooks were in Nepali, Nepali is not the first language of many of
the students and it would not be feasible to write editions of each book in,
say, Maithili or Bhojpuri. Next, despite the official language of instruction
being English, there are commonly accepted ways to work around this, and these
exist throughout all levels in the Nepali system of education, form the very
beginning. Many schools use the least amount of paper for their students and
rely on memorization.
people study in a resource-limited environment
In nursing, nobody can afford to buy a personal textbook; libraries are not amply stocked, and the jargon of medicine and nursing is difficult to learn ( this is true even for American nursing students). There is a lot of highly specialized vocabulary. Nobody studies “alone” – they study in groups. In other words, five students get together, the best English-speaker reads it out loud, and they discuss it in Nepali to gain comprehension. In the cities more students own a laptop but this is not the case everywhere.
There is nothing wrong with Nepali language
Use of Nepali bhasa is actually close to what it should be. This is Nepal; the patients speak Nepali; the nurses will work in Nepali language to meet Nepali health needs. But there is tremendous variability of English language proficiency across the country. If you meet a nursing student in Kathmandu who is fluent, do not think that they represent all nursing students everywhere. In my classes that I teach, I start each session with a quick survey of language ability since I lecture in English.
I looked at the sample question in the link above from 2012, and I would say that these do not reflect what we would call a “nursing focus” in USA. In brief, the questions rely too much on nurse’s vocabulary and not on the actual decisions a nurse would need to make. In USA there are many examples of the type of question that would appear on the licensure exam. Dozens of sites showing sample questions can be found by Google. For that matter, the National Council of State Boards of Nursing in USA publishes their own test map, and it is very very different than the one for Nepal, being “concept based.” My experience constructing exams in USA tells me that none of the questions in the 2012 sample would be acceptable. Also, when a nurse struggles with language, is it reasonable to impose a 180-minute limit on the exam? Are there numbers available as to who was unable to complete the exam in this time?
So, the exam results leave many
questions unanswered, starting with the validity of the exam, the way it is
delivered, and the way it is used.
Please feel free to share, and to comment below. I invite feedback on this blog, especially if it will improve accuracy. If you wish to give feedback but are reluctant to speak publicly, send an email to me at firstname.lastname@example.org
Also, I will add another blog on the topic of what I think needs to be done. Stay tuned.