A prescription for better prescribing

Many medical students are unprepared to properly prescribe drugs after they qualify, argue Jeffrey K Aronson and colleagues. Will your training equip you with the skills you need?

The final exams are over. The years of hard work at your United Kingdom medical school have paid off. You are ready to start foundation year 1. But a small anxiety emerges- are you prepared? In particular, are you properly trained in practical drug therapy and prescribing? We believe you may not be.

In July we drew attention, yet again, to what we and many others perceive to be a serious problem in British medicine-poor prescribing.^{w1 w2} We emphasised that deficiencies are not confined to the UK, and three days later the Institute of Medicine in the United States independently expressed similar concerns.^w3 The chairman of the medical academic staff committee of the British Medical Association later concurred,^w4 and the Healthcare Commission urged the NHS to improve prescribing.^w5

Evidence of poor prescribing in the UK is abundant. Effective treatments, such as angiotensin converting enzyme inhibitors for heart failure ^w6 and statins for hyperlipidaemia,^w7 are often under- prescribed. Prescription errors are common,^w8 especially when new doctors start work in hospitals.^w9 About 6.5% of admissions to hospital are related to adverse drug reactions, with an associated mortality of 0.15%; this costs the NHS £466m (€692m, $881m) annually.^w10

The reasons for these errors are manifold.^{w8 w11} Some relate to system failures. For example, why does every NHS hospital have its own inpatient prescribing sheet? There should be a single nationwide form.

Another fundamental problem is that medical students are not adequately instructed. In 1994, UK medical students received a median 61 hours of teaching related to pharmacology, clinical pharmacology, and therapeutics.^w12 Since then the numbers of pharmacologists and clinical pharmacologists in the UK (and thus the amount of teaching) have fallen.^{w13 w14} In contrast, nurses seeking to obtain the Postgraduate Certificate in Prescribing from the University of Liverpool must complete a training course of 162 hours of theory and 90 hours of practice.^w15

Prescribing is becoming increasingly difficult, and the inherent risks of adverse reactions and interactions have increased. Modern drugs are pharmacologically complex, the population is ageing, and the use of polypharmacy is increasing. The root cause of prescribing errors among final year medical students is the lack of an integrated scientific and clinical knowledge base.^w16 Tomorrow's doctors need a firm grounding in the principles of pharmacology and clinical pharmacology, linked to practical therapeutics,^w17 so that they can weigh up the potential benefits and harms of treatment; understand the sources of variability in drug response; base prescribing decisions on sound evidence; and monitor drug effects appropriately. The British Pharmacological Society has developed a syllabus to ensure that medical students are adequately trained.^w18 It should be adopted by and implemented in all UK medical schools.

The box shows our practical prescription to improve prescribing.^w19 It is not enough to teach prescribing skills- they must also be assessed. Drug therapy cuts across all medical practice, and modern medicines are too potent for the newly qualified graduate to be allowed to prescribe without providing evidence of competence. Students should not be allowed to compensate for poor performance in this high risk activity by good performances in other areas.

JIM VARNEY/SPL
One swallow does not a summer make

Pharmacologists and clinical pharmacologists should be expected to lead the way in providing the necessary teaching and assessments. However, there are too few of them to handle the entire burden. Their clinical colleagues should be encouraged to devote specific sessions to practical drug treatment, not least because other specialists and general practitioners will draw on and provide extra practical experience. Partnerships with other prescribers, such as pharmacists and nurses, might also be useful.

Medical students have expressed their desire for more teaching in practical drug therapy and prescribing.^{w19 w20} They too can play their part by encouraging their medical schools to provide more tuition. Together with Simon Maxwell at the University of Edinburgh, Amy Heaton, a medical student, has prepared a short web based questionnaire that asks medical students how well their course prepares them for prescribing drugs (http://fs12. formsite.com/amyheaton/pharmacology therapeutics/index.html). We encourage all medical students and doctors in their first foundation year to take a couple of minutes to fill it in. We also challenge all people involved in teaching students and training doctors to implement these proposals. After all, we shall all benefit from better prescribing.

References w1-w20 are on studentbmj.com.

Jeffrey K Aronson, president elect
Email: jeffrey.aronson@clin-pharm.ox.ac.uk
Graeme Henderson, president

David J Webb, chairman of the committee of heads, British Pharmacological Society, London EC1V 2SC

Michael D Rawlins, professor, Wolfson Unit of Clinical Pharmacology, University of Newcastle, Newcastle upon Tyne NE2 4HH



studentBMJ 2006;14:309-352 September ISSN 0966-6494

1. BBC News. Concerns over medics’ drug skills. http://news.bbc.co.uk/1/hi/health/5192372.stm (accessed 9 Aug 2006).
2. McCartney M. A prescription for success. Financial Times Weekend, 29/30 July 2006: W9.
3. Kaisernetwork.org. Daily reports. Medication errors harm 1.5M US residents annually, new Institute of Medicine report says. www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=38636 (accessed 9 Aug 2006).
4. Pritchard L. Ignore prescribing problem at your peril, MASC warns. BMA News, July 29, 2006: 2.
5. BBC News. NHS drug error ‘crackdown’ urged. http://news.bbc.co.uk/1/hi/health/4780487.stm (accessed 10 Aug 2006).
6. Mangoni AA, Jackson SHD. The implications of a growing evidence base for drug use in elderly patients. Part 2: ACE inhibitors and angiotensin receptor blockers. Br J Clin Pharmacol 2006;61:502-12.
7. Aronson JK. Prescribing statins. Br J Clin Pharmacol 2005;60:457-8.
8. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002;11:340-4.
9. Audit Commission. A spoonful of sugar - improving medicines management in hospitals. London: Audit Commission, 2001.
10. Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ 2004;329:15-9.
11. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002;359:1373-8.
12. Walley T, Bligh J, Orme M, Breckenridge A. Clinical pharmacology and therapeutics in undergraduate medical education in the UK: current status. Br J Clin Pharmacol 1994;37:129-35.
13. Maxwell SR, Webb DJ. Clinical pharmacology - too young to die? Lancet 2006;367:799-800.
14. The Academy of Medical Sciences Forum. Drug safety. London: Academy of Medical Sciences, 2005.
15. University of Liverpool. Extended Formulary & Supplementary Nurse Prescribing. http://www.liv.ac.uk/Nursing/courses/Nurse%20Prescribing.html (accessed 9 Aug 2006).
16. Boreham NC, Mawer GE, Foster RW. Medical students’ errors in pharmacotherapeutics. Med Educ 2000;34:188-93.
17. Working Party on Clinical Pharmacology. Clinical pharmacology in a changing world. London: Royal College of Physicians, 1999.
18. Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow’s doctors. Br J Clin Pharmacol 2003;55:496-503.
19. Aronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006;61:478-91.
20. Ellis A. Prescribing rights: are medical students properly prepared for them? BMJ 2002;324:1591.

       

           

	EDITORIALS A prescription for better prescribing       Jeffrey K Aronson, Graeme Henderson, David J Webb, Michael D Rawlins (September 2006)
	Dr Raghesh varot kangath (August 26th, 2006)       lecturer, Dr SMCSI Medical College, Trivandrum, Indiadrraghesh@yahoo.com
	The article correctly points to the poor prescription writing skills of young doctors. This usually leads to a lot of confusion. This happened sometime ago to one of my collegues- He wrote a prescription in hurry and gave to the patient. The patient returned after six hours telling that he could'nt get the prescribed medicine anywhere and that the medical store personnel were quite unaware of the drug. The most funny part is that even the prescribing doctor took some time to read his own writing and he had written the patient's name in the place of drug.

	EDITORIALS A prescription for better prescribing       Jeffrey K Aronson, Graeme Henderson, David J Webb, Michael D Rawlins (September 2006)
	Dr Anil Singh (September 19, 2006)       Assistant professor, Pharmacology, Jamnagar docanil@yahoo.com
	as the students pass out form the medical colleges it is assumed that with the acquiring of the medical knowledge as per the medical curriculum they have also gained knowledge for the prescription writing. it must be remembered-prescription writing as an exercise is covered in the 2nd MBBS and the students actually get to write prescriptions only after a gap of one and half years later when they are doing their internship in various departments. i think there should be revised exercise in good and legible prescription writings during their internship practice and they should be asked to dispense the medicine at the pharmacy counters so that they realise the actual utility of this exercise.

	EDITORIALS A prescription for better prescribing       Jeffrey K Aronson, Graeme Henderson, David J Webb, Michael D Rawlins (September 2006)
	Dr Sathish KBV Reddy (September 24, 2006)       SHO with Experience---General Surgery, Whiteabbey Hospital, Belfast drsathishreddy@yahoo.com
	Prescription writing is an art which every doctor must master early in their careers to give the best quality of care to their patients. The arguement in this present article is an eye opener and a good prescription for prescrition writing. Recent surveys both in the GP Practices in the community and also in hospital practices it has been shown that Medication errors are common and there is no structured method to prevent these errors, although the causes for these errors are manifold. The root cause of prescribing errors is the lack of an integrated scientific and clinical knowledge base as stated by the author. From the F1 point of view guidance on Prescription writing, discharge advice, contributing on the ward rounds, communicating with the patients in the ward, clinical skills like venflons, bloods for inv, catheterisations etc should be addressed accurately and appropriately. A common approach of induction and supervised guidance on the ward is not sufficient but a radical approach as prescribed in this article should help us to give the best quality of care to our patients.