Junior doctors prescribing: enhancing their learning in practice

AIM

This aim of this paper was to explore new doctors'' preparedness for prescribing.

METHODS

This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n = 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n = 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n = 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s.

RESULTS

Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools.

CONCLUSION

The results form part of a larger study ‘Are medical graduates fully prepared for practice?’. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing.     

Development of learning outcomes for an undergraduate prescribing curriculum (British Pharmacological Society prescribing initiative)

AIMS

The question of whether new medical graduates are adequately prepared for the challenge of prescribing has been raised. Although broad outcomes for prescribing competency have been agreed, clarity is needed on the detailed outcomes expected of new graduates. This study aimed to create a consensus on the required competencies for new graduates in the area of prescribing.

METHODS

We used a modified Delphi approach based on the findings of a systematic review of educational interventions for improved prescribing. Panellists were asked to rank the importance of a list of 53 possible learning outcomes and to add any additional outcomes felt to be missing.

RESULTS

Of the 48 experts who were invited to participate, 28 agreed (58%). Forty-five learning outcomes were included from the original list of 53. A further nine outcomes were suggested by panellists, of which five were included. The wording of three outcomes was changed in line with suggestions from the panellists. Many of the agreed outcomes relate to improving patient safety through medication review, checking appropriateness of the drug for the patient, recognizing the prescriber''s limitations and seeking advice when needed. Enhanced communication with the patient and healthcare team, better documentation in the notes and discharge letters were key areas featured in this Delphi exercise.

DISCUSSION

This study has identified 50 learning outcomes for teaching prescribing. These build on the existing British Pharmacological Society document by focusing specifically on prescribing, with greater emphasis on avoiding medication errors and better communication.     

How well are general practice trainees prepared for paediatric prescribing?

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT
• Children make up a significant proportion of a general practitioner's (GP's) prescribing workload.
• The realisation that children cannot be assumed to be little adults and may require specialized prescribing and therapeutic knowledge is relatively recent.
• Off-label medicines, which have been associated with an increased frequency of adverse drug reactions, are commonly prescribed by GPs to children.
WHAT THIS STUDY ADDS
• The majority of GP trainees believe that their undergraduate and postgraduate training in paediatric therapeutics is insufficient for their coming requirements in primary care.
• Approximately one-third of GP trainees do not undertake any paediatrics training prior to starting work as a GP.
• Off-label and unlicensed prescribing are the most poorly covered areas of paediatric therapeutics in universities/university hospitals.
• Those trainees who do undergo paediatric training during their vocational years report increased paediatric prescribing confidence.
AIMS AND METHODOLOGY We invited 232 General Practice Trainees to complete an on-line questionnaire to assess how they rated their training for the task of paediatric prescribing and therapeutics in the community.
RESULTS Of the 166 (71%) respondents who completed the questionnaire, 26.5% recalled specific teaching about paediatric prescribing and 59.6% covering one or more relevant topic during their undergraduate years. Undertaking a paediatric post during vocational training was associated with greater prescribing confidence ( P  < 0.001); however, 35% of respondents were not intending to undertake such a post.
CONCLUSION This study suggests that many GP trainees perceive their paediatric prescribing training as inadequate.     

Antimicrobial prescribing at a university hospital: justified or 'just in case': testing a new scoring system as a key quality indicator

OBJECTIVE: To evaluate the quality of antimicrobial drug prescribing at a university hospital in the Department of Medicine, by using a new scoring system as a quality indicator. METHODS: Design: a prospective, longitudinal survey, during a 21-week period. The necessity of antimicrobial treatment of all in-patients at the Department of Medicine, to whom new antimicrobials were prescribed, was assessed by using a scoring system based on the presence of signs and symptoms of an infection. If the sum's total score was 3 or more, the antimicrobial treatment was deemed justifiable; if the score was less than 3, the antimicrobial treatment was regarded as questionable. Setting: Department of Medicine (279 hospital-beds) at the University Hospital Center Rijeka, a 1200-patient-bed teaching hospital in Croatia. RESULTS: Antimicrobials were prescribed to 15% of the total patients. They were given as a treatment to 89% of the patients, and in 67% of the cases, this treatment was administered empirically. According to the scoring system, 29% of the patients did not have a justified indication for antimicrobial treatment. CONCLUSION: The proposed quality indicator (scoring system) that we used is a simple method for the quality assessment of antimicrobial use. It has indicated areas that require in-depth analysis.     

Construction and evaluation of a web-based interactive prescribing curriculum for senior medical students

AIMS: To develop and evaluate for the National Prescribing Service (NPS) a web-based interactive prescribing curriculum for Australian senior medical students based on the World Health Organization's Guide to Good Prescribing. METHODS: Teachers of prescribing from all Australian medical schools in 2000 wrote 12 case-based modules which were converted to on-line format. Objective evidence was provided for selecting first-line medicines from available alternatives by comparing efficacy, safety, convenience and cost. The curriculum was made available to final year students in 2001 and was evaluated by measuring use from web statistics and by semistructured interviews with 15 teachers (2003) and on-line surveys of 363 students over 2003 and 2004. RESULTS: By 2004 the curriculum was used by nine of 11 possible medical schools. Uptake increased each year from 2001 and all 12 modules were accessed consistently. Student access was significantly (P < 0.001) greater when prescribing was an assessable part of their course. Teachers' evaluations were uniformly supportive and the curriculum is seen as a valuable resource. Student responses came from a small proportion of those with password access but were also supportive. Over half of student respondents had created their own evidence-based formulary. CONCLUSIONS: A collaborative venture initiated by the NPS with Australian medical schools has been successfully implemented in most courses. Teachers find the resource of high quality. Student respondents find the curriculum valuable in developing their own prescribing skills. It is best delivered by self-directed study followed by tutorial discussion of prescribing decisions.     

Effectiveness of a national approach to prescribing education for multiple disciplines

Aims

To evaluate the effectiveness of a national approach to prescribing education on health professional students’ prescribing and therapeutics knowledge, across multiple disciplines.

Methods

In a university examination setting, 83 medical, 40 pharmacy and 13 nurse practitioner students from three different universities completed a set of multiple choice questions (MCQs) before and after completing an online module from the National Prescribing Curriculum (NPC). To minimize overestimation of knowledge, students had to indicate the level of certainty for each answer on a three‐point scale. MCQs were scored using a validated certainty‐based marking scheme resulting in a composite score (maximum 30 and minimum −60). Students were asked to rate their perception of usefulness of the module.

Results

At the pre‐module phase, there were no significant differences in the composite MCQ scores between the medical (9.0 ± 10.3), pharmacy (10.2 ± 10.6) and nurse practitioner (8.0 ± 10.7) students. The scores improved significantly for all groups at the post‐module phase (P < 0.01 for all groups) by similar extents (post‐module results: medical, 14.5 ± 9.6; pharmacy, 14.4 ± 9.9; nurse practitioner, 12.1 ± 9.6). 39.4% of the MCQs answered incorrectly with high level of certainty at the pre‐module phase were still answered incorrectly with high level of certainty at the post‐module phase. Almost all students (with no significant difference between the groups) found the NPC modules, post‐module MCQs and feedback useful as a learning tool.

Conclusions

A national online approach to prescribing education can improve therapeutics knowledge of students from multiple disciplines of health care and contribute towards streamlining interdisciplinary learning in medication management.     

Prescribers prefer people: The sources of information used by doctors for prescribing suggest that the medium is more important than the message

AIMS: The sources of prescribing information are legion but there is little knowledge about which are actually used in practice by doctors when prescribing. The aims of this study were to determine the sources of prescribing information considered important by doctors, establish which were used in practice, and investigate if hospital and primary care physicians differed in their use of the sources. METHODS: Two hundred general practitioners (GPs) and 230 hospital doctors were asked to rate information sources in terms of their importance for prescribing 'old' and 'new' drugs, and then to name the source from which information about the last new drug prescribed was actually derived. RESULTS: Among 108 GPs, the Drugs and Therapeutics Bulletin and medical journal articles were most frequently rated as important for information on both old and new drugs while pharmaceutical representatives and hospital/consultant recommendations were more important for information on new drugs, as opposed to old. In practice, information on the last new drug prescribed was derived from pharmaceutical representatives in 42% of cases and hospital/consultant recommendations in 36%, with other sources used infrequently. Among 118 hospital doctors, the British National Formulary (BNF) and senior colleagues were of greatest theoretical importance. In practice, information on the last new drug prescribed was derived from a broad range of sources: colleagues, 29%; pharmaceutical representatives, 18%; hospital clinical meetings, 15%; journal articles, 13%; lectures, 10%. GPs and hospital doctors differed significantly in their use of pharmaceutical representatives (42% vs 18%) and colleagues (7% vs 29%) as sources of prescribing information (P < 0.0001 for both). CONCLUSIONS: The sources most frequently rated important in theory were not those most used in practice, especially among GPs. Both groups under-estimated the importance of pharmaceutical representatives. Most importantly, the sources of greatest practical importance were those involving the transfer of information through the medium of personal contact.