Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience

AIMS: To determine whether, in retrospect, first year foundation (FY1) programme doctors believe that their undergraduate education in Clinical Pharmacology and Therapeutics (CPT) has prepared them to prescribe safely and rationally. METHODS: This was a prospective questionnaire survey. Ninety FY1 doctors, employed in the Aberdeen Teaching Hospitals, participated. RESULTS: Seventy-one percent of FY1 doctors completed the survey. Thirty percent of respondents rated their knowledge of CPT as poor or worse and only 8% as good; 74% reported having witnessed an adverse drug reaction (ADR) and 55% a drug-drug interaction, a number of which had resulted in patient morbidity or mortality. Many of these events were reported to have been avoidable or predictable with more extensive undergraduate and postgraduate training. Forty-two percent of respondents stated that they had not been taught enough about avoiding ADRs and 60% about avoiding drug-drug interactions during their undergraduate years. Over 75% of respondents reported high levels of confidence for the unsupervised use of warfarin, nonsteroidal analgesics and opiate analgesics. In retrospect, FY1 doctors would like more undergraduate teaching in prescribing for special patient groups, ADRs, drug interactions, together with CPT in their postgraduate teaching programme. CONCLUSIONS: FY1 doctors believe that their undergraduate and postgraduate training in CPT is insufficient to prescribe safely and rationally. This study adds further weight to the call for an increase in the training of junior doctors in the rational and safe use of medicines.     

Junior doctor-led ‘near-peer’ prescribing education for medical students

Aims

Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors.

Methods

One hundred and ninety-six tutorials were delivered to 183 students during 2010–2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis.

Results

The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors.

Conclusions

A ‘near-peer’ junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials.     

Prevention of medication errors: teaching and training

1. Poor prescribing is probably the most common cause of preventable medication errors in hospitals, and many of these events involve junior doctors who have recently graduated. Prescribing is a complex skill that depends on a sound knowledge of medicines, an understanding of the principles of clinical pharmacology, the ability to make judgements concerning risks and benefits, and ideally experience. It is not surprising that errors occur.
2. The challenge of being a prescriber is probably greater now than ever before. Medical education has changed radically in the last 20 years, reflecting concerns about an overburdened curriculum and lack of focus on social sciences. In the UK, these changes have resulted in less teaching in clinical pharmacology and practical prescribing as guaranteed features of undergraduate training and assessment. There has been growing concern, not least from students, that medical school training is not sufficient to prepare them for the pressures of becoming prescribers. Similar concerns are being expressed in other countries. While irrefutable evidence that these changes are related to medication errors identified in practice, there is circumstantial evidence that this is so.
3. Systems analysis of errors suggests that knowledge and training are relevant factors in causation and that focused education improves prescribing performance. We believe that there is already sufficient evidence to support a careful review of how students are trained to become prescribers and how these skills are fostered in the postgraduate years. We provide a list of guiding principles on which training might be based.     

Educating European (junior) doctors for safe prescribing

Evidence of poor prescribing is widespread including overuse of medicines, underuse of effective medicines, avoidable adverse drug reactions and medication errors. Junior doctors who have recently graduated are responsible for much of the prescribing that takes place in hospitals and are implicated in many of the adverse medication events. Analysis of such events suggests that lack of knowledge and training underlies many of them and it has been shown that dedicated training can increase prescribing performance. In the context of these problems, it is a matter of increasing concern that recent changes to undergraduate medical education may have reduced exposure to clinical pharmacology, a discipline dedicated to optimal practice in relation to medicines. For this reason, the European Association of Clinical Pharmacology and Therapeutics (EACPT) and British Pharmacological Society (BPS) jointly organized a meeting to explore (i) the state of undergraduate education in clinical pharmacology in Europe, (ii) the knowledge and competencies in relation to medicines that should be expected of a new graduate, (iii) assessments that might demonstrate that this minimum standard had been reached, (iv) a curriculum that might help medical students to achieve this standard and (v) how competence can be developed in the postgraduate phase. It was agreed that the lack of exposure to clinical pharmacology is a cause for concern at a time when the challenges facing junior prescribers have never been greater. The potential for undertaking further research was discussed.     

The feasibility of incorporating structured therapeutic consultations with real patients into the clinical clerkship internal medicine

This study aims to determine the feasibility of incorporating structured therapeutic consultations (TCs) into the clinical clerkship internal medicine. TCs were considered feasible if students were able to draw up a therapeutic plan and carry out a TC, and if students and their supervisors considered TCs workable and useful. From March 2008 to October 2009, medical students carried out a “diagnostic” and subsequent “therapeutic” consultation with the same patient during their clinical clerkship internal medicine at the VU University Medical Center. After the diagnosis was established, the student had to formulate a therapeutic plan and then carry out a TC with the patient, supervised by a clinician. The supervisor assessed the therapeutic plan and how the student conducted the TC. Both the student and the supervisor received a questionnaire about the workability and usefulness of the TC. On average, students' performance in drawing up a therapeutic plan was awarded a score of 4.4 on a five-point scale, and the TC performance of 96?% of the students was considered amply sufficient or better. Eighty-three percent of the supervisors agreed or strongly agreed with the statement that the TC is a worthwhile addition to the clerkship, and 67?% of the students indicated that they would like to perform more TCs. This study shows that incorporating a structured TC with a real patient into the clinical clerkship internal medicine is both feasible and worthwhile. This may be an important step to improving the prescribing skills and attitudes of junior doctors and residents and to reducing their prescribing errors after graduation.     

Educating nonmedical prescribers

The last decade has seen developments in nonmedical prescribing, with the introduction of prescribing rights for healthcare professionals. In this article, we focus on the education, training and practice of nonmedical prescribers in the UK. There are around 20 000 nurse independent prescribers, 2400 pharmacist supplementary/independent prescribers, several hundred allied health professional supplementary prescribers and almost 100 optometrist supplementary/independent prescribers. Many are active prescribers, managing chronic conditions or acute episodes of infections and minor ailments. Key aims of nonmedical prescribing are as follows: to improve patient care; to increase patient choice in accessing medicines; and to make better use of the skills of health professionals. Education and training are provided by higher education institutions accredited by UK professional bodies/regulators,namely, the Nursing and Midwifery Council, General Pharmaceutical Council, Health Professions Council and General Optical Council. The programme comprises two main components: a university component equivalent to 26 days full-time education and a period of learning in practice of 12 days minimum under the supervision of a designated medical practitioner. Course content focuses on the following factors: consultation, decision making, assessment and review; psychology of prescribing; prescribing in team context; applied therapeutics; evidence-based practice and clinical governance; legal, policy, professional and ethical aspects; and prescribing in the public health context. Nonmedical prescribers must practise within their competence, demonstrating continuing professional development to maintain the quality engendered during training. Despite the substantial progress, there are several issues of strategy, capacity, sustainability and a research evidence base which require attention to fully integrate nonmedical prescribing within healthcare.     

e-Learning initiatives to support prescribing

Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing.     

How could undergraduate education prepare new graduates to be safer prescribers?

This review examines the extent to which undergraduate prescribing education prepares graduates for the complexities of prescribing in the workplace context. In order to prescribe safely, it is important for medical students to acquire prescribing expertise. We have developed a theoretical model, based on theories of expertise development, which acknowledges the inherent complexity of the task itself, the social context and the relationship between the two. We have examined the empirical evidence on educational interventions for prescribing by reviewing the extent to which the interventions acknowledge the different components of our theoretical model. Fifteen empirical studies met our inclusion criteria and were reviewed in detail. All the studies were conducted between 2002 and 2010, six were controlled trials, six were before and after studies and three were prospective observational studies. We found that most studies focused on improving and evaluating students' knowledge and skills, although they used different approaches to doing so. These aspects of prescribing only constitute a small part of our theoretical model of prescribing expertise. Other important components, such as social context, metacognition and training transfer, were neglected. We suggest that educational interventions need to account for the integrated nature of learning to prescribe and take a more contextualized approach which considers the task as a whole, rather than isolated constituent parts. In doing so, prescribing education could equip graduates with the necessary expertise to judge and respond to situations, enabling them to prescribe safely, or seek the help to do so, in the unpredictable and complex context of workplaces.     

Non-medical prescribing

In the UK, the Medicines Act 1968 limited the legal right to prescribe medicines to doctors, dentists and veterinary surgeons. Nearly 40 years later, non-medical prescribing, the extension of prescribing responsibilities to nurses, pharmacists and other healthcare professionals, is a key development in the NHS. Within England, from May 2006, certain nurse and pharmacist prescribers can prescribe any licensed medicine (except most controlled drugs) within their sphere of competence. Here we discuss the historical context, the different types and the clinical implications of non-medical prescribing.     

Education in clinical pharmacology at the Rijeka School of Medicine, Croatia

Objective: Irrational drug prescribing is a global problem that exists both in developed and developing countries. Education is the key to improved effectiveness and safety in drug therapy. Development of clinical pharmacology (CP) as an independent discipline at the Rijeka School of Medicine has been slow and unsatisfactory. It was taken only as a part of some postgraduate courses. In the 1995/1996 academic year clinical pharmacology was offered for the first time to sixth year medical students as a non-mandatory subject. The purpose of this study was to emphasize the importance of education in clinical pharmacology at the Rijeka School of Medicine. Methods: This survey was an uncontrolled study based on responses to questionnaires and a test consisting of written patient problems given to sixth year medical students and to general practitioners who were following a course in clinical pharmacology. Results: The results of the questionnaire showed that both undergraduate and postgraduate students consider that they are not being adequately trained to prescribe drugs rationally and that they believe that clinical pharmacology should become a mandatory subject in the undergraduate medical curriculum. The results of the written patient problem test support this. Both groups of students demonstrated greater skills in solving the diagnostic part than the therapeutic part of the test. A great improvement in the students' ability to solve the therapeutic part was observed after they had completed the CP course. Conclusion: The results of this survey underline the necessity of education in clinical pharmacology.     

Prescribing and the core curriculum for tomorrow's doctors: BPS curriculum in clinical pharmacology and prescribing for medical students

Prescribing is one of the commonest tasks expected of new doctors and is a complex process involving a mixture of knowledge, judgement and skills. Preparing graduates to be prescribers is one of the greatest challenges of modern undergraduate medical education and there is some evidence to suggest that training could be improved. The aims of this article are (i) to review some of the challenges of delivering effective prescribing education, (ii) to provide a clear statement of the learning outcomes in clinical pharmacology and prescribing that should be expected of all medical graduates and (iii) to describe a curriculum that might enable students to achieve these outcomes. We build on the previous curriculum recommendations of the British Pharmacological Society and take into account those of other key bodies, notably the General Medical Council. We have also reviewed relevant evidence from the literature and set our work in the context of recent trends in medical education. We divide our recommended learning objectives into four sections: principles of clinical pharmacology, essential drugs, essential therapeutic problems and prescribing skills. Although these will not necessarily be accepted universally we believe that they will help those who design and map undergraduate curricula to explore potential gaps and identify improvements.