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Impact of a compulsory final year medical student curriculum on junior doctor prescribing J. S. Thomas,1 M. Koo,2 S. Shakib,3 J. Wu4 and S. Khanal4 1
Clinical Education, University of Adelaide, 3Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia, 2Educational Design and
Support and 4Program Evaluation, NPS MedicineWise, Sydney, New South Wales, Australia
Key words prescribing, medical education, medication safety. Correspondence Josephine Thomas, Clinical Education, University of Adelaide, 1-4 Eleanor Harrald building, 50 North Terrace, Adelaide, SA 5000, Australia. Email: [email protected] Received 18 June 2013; accepted 9 October 2013. doi:10.1111/imj.12316
Abstract Background: Attendance at face-to-face sessions and completion of online components of the National Prescribing Curriculum was made compulsory for final year medical students at the University of Adelaide in 2010. Aims: To determine the impact of a compulsory prescribing curriculum for final year medical students on their prescribing competencies at the start of clinical practice. Graduates’ attitudes to their medical school training in prescribing were also surveyed. Methods: Two cohorts of medical graduates from the University of Adelaide who commenced medical practice in 2010 and 2011 were required to complete a prescribing task using the National Inpatient Medication Chart (NIMC) at orientation and after 6 months of clinical practice. The main outcome measure was a performance in a scenario-based prescribing test, as determined by test scores and overall safety of prescriptions at orientation and 6 months of clinical practice. Results: There was a small difference in the average total score for the prescribing task between the 2010 and 2011 cohorts at orientation (P = 0.0007). The 2011 cohort had a higher number of safer charts at commencement of practice. We found no difference between the 2010 and 2011 cohorts in attitudes towards their undergraduate pharmacology education, and new graduates feel poorly prepared. Conclusion: Medical graduates who are required to complete a practically oriented prescribing curriculum in final year perform slightly better on a prescribing assessment at commencement of practice. More work on preparing graduates for this complex task before graduation is needed.
Introduction Deficiencies in the ability of junior doctors to prescribe safely and adequately for hospital inpatients have been highlighted in the medical literature.1,2 Prescribing medications is a critical part of medical practice and begins from the first day of practice. While many of the prescribing errors are attributed to the work environment and junior doctor workload, some authors have highlighted the inability of medical curricula to prepare junior doctors for this task.3–5 Junior doctors themselves cite deficiencies in their training as a contributor to their inadequate prescribing skills.5,6 The National Prescribing Curriculum (NPC) (http:// www.nps.org.au/npc) was developed by NPS MedicineWise (formerly known as the National Prescribing Service) in collaboration with the Australasian
Funding: None. Conflict of interest: None.
156
Society of Clinical and Experimental Pharmacologists and Toxicologists and was made available to all Australian medical schools in 2001.7 The University of Adelaide Medical School utilises the NPC7 in the final year of a 6-year undergraduate medical curriculum. The University of Adelaide programme consists of 10 face-to-face tutorials with a clinical pharmacologist to complement the online modules. Following completion of each module, a face-to-face tutorial session is held where the students can ask questions to clarify and further expand on the work they have completed online. These prescribing sessions integrate well with previous elements of the University of Adelaide medical school curriculum, which provide basic clinical pharmacological and pharmacotherapy concepts. Previously, the uptake of the prescribing curriculum at the University of Adelaide was very poor, with attendance as low as 25% in some sessions. To enhance the prescribing skills of all medical graduates, the sixth year prescribing curriculum was made a compulsory element for final year students from January 2010. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
Prescribing curriculum study
As a large proportion of University of Adelaide graduates choose to undertake their internship at the Royal Adelaide Hospital (RAH), the transition of the prescribing curriculum from optional to compulsory offered a unique opportunity to evaluate the impact of completing the course in the prescribing competencies of new graduates.
Methods Study design This study aimed to evaluate new graduates’ competency in prescribing and to compare the effect of completing a compulsory prescribing curriculum. All interns commencing duty at the Royal Adelaide Hospital in January 2010 and 2011 were given a prescribing task during their orientation programme. A survey was also conducted to obtain the graduates’ views on the undergraduate prescribing curriculum. In January 2010, final year medical students at the University of Adelaide were required to complete the NPC online modules and attend at least 95% of the face-to-face tutorials. Failure to complete the programme was a barrier to graduation; these students formed the 2011 cohort. Interns who were graduates of the University of Adelaide thus formed a control (2010 cohort) and intervention (2011 cohort) group for comparison. Although we were only targeting University of Adelaide graduates, all interns were included in the survey to simplify the study process (this was easier than selecting a group). Analysis was then limited to the target group. Ethics approval was obtained from the Royal Adelaide Hospital Ethics Committee, and written consent was obtained from all participants before their inclusion in the study. The task was performed prior to any orientation by the pharmacy or pharmacology departments, and was the same case scenario utilised by Hilmer et al.5 in their study of new graduates at NSW hospitals in 2008. The task was modified slightly from Hilmer’s study (to exclude the discharge prescription component). This was necessary due to changes in the local hospital process for discharge scripts. Study participants were required to write a prescription for the patient on the Australian National Inpatient Medication Chart (NIMC).6 All graduates were supplied with the necessary drug information for the prescribing tasks including the approved product information for each drug related to the case from local resources including Monthly Index of Medical Specialties8 and Australian Medicines Handbook9 monograph, in addition to prescribing guidelines for neutropenic fever from Therapeutic Guidelines,10 and a copy of the NIMC.6 Following 6 months of medical practice, interns were reassessed with the same prescribing task. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
Prescriptions were scored independently by two clinical pharmacologists (JT and SS) according to pre-specified criteria. Discrepancies were reconciled by consensus. One point was awarded for each of the following parameters (total possible marks = 36): • At least two unique patient identifiers recorded (e.g. name and date of birth) • Complete allergies recording • Regular medications charted (for each medication) – one point for each of: date, route, generic name, dose/ frequency, signature/name of prescriber • Slow release box ticked for sustained-release morphine (MS Contin) • Paracetamol charted (as needed or regular) – one point for each of: date, generic name, route, dose/frequency, signature/name of prescriber • Ticarcillin with clavulanic acid (Timentin; GlaxoSmithKline, Aspen Pharmacare Australia Pty Limited, Sydney, NSW, Australia) – not charted due to documented penicillin allergy • Gentamicin – not charted (in preference for cefepime as per supplied guidelines) • Additional ‘as needed’ analgesia charted – one point each for: opioid, immediate release, oral route, appropriate dose (equivalent 10–15 mg oral morphine), frequency 2–4 hourly, legal opioid order To add a more realistic measure of competence, charts were also classified as ‘safe, moderately unsafe or severely unsafe’ by JT and SS according to potential to cause harm, based on a standardised method.11 All interns were given general feedback about prescribing performance at the end of orientation; in addition they were offered the option to receive individual feedback on their performance by email.
Statistical analysis Each parameter was given one mark for correct completion, and the total task score was a count of parameters completed correctly. The changes in the average total score from orientation to 6 months in the two cohorts were compared by using a marginal log-linear model using generalised estimating equations (GEE) with a Poisson distribution and a log link function. GEE proportional odds regression, with a multinomial distribution and a cumulative logit link function was used to estimate the odds of the graduates writing safer prescription over the 6-month duration for both cohorts. Graduates’ attitude towards their undergraduate pharmacology education was also compared between the two cohorts. The responses were aggregated to three groups of ‘strongly disagree/disagree’, ‘neutral’ and ‘strongly agree/agree’. Fisher’s exact test was used to assess the 157
Thomas et al.
Table 1 Level of safety of the prescriptions written by interns at orientation and 6 months of their internship Level of safety
Safe Moderately unsafe Severely unsafe
2010 cohort (n = 50)
Table 2 The proportional odds of interns completing a safer chart Total scores
2011 cohort (n = 59)
Orientation (%)
6 months (%)
Orientation (%)
6 months (%)
13 (26.0) 14 (28.0) 23 (46.0)
25 (50.0) 17 (34.0) 8 (16.0)
22 (37.3) 15 (25.4) 22 (37.3)
39 (66.1) 16 (27.1) 4 (6.8)
association between the two cohorts and graduates’ attitude. Results were considered statistically significant if P-value < 0.05. The analyses were carried out with the use of statistical analysis software SAS version 9.13 (SAS Institute Inc., Cary, NC, USA).
At orientation 2011 cohort vs 2010 cohort 2010 cohort 6 months vs orientation 2011 cohort 6 months vs orientation After 6 months practice 2011 cohort vs 2010 cohort
Odds ratio
95% CI
P-value
1.59
0.77–3.29
0.21
3.40
1.54–7.51
0.002
4.13
2.01–8.49
Impact of a compulsory final year medical student curriculum on junior doctor prescribing J. S. Thomas,1 M. Koo,2 S. Shakib,3 J. Wu4 and S. Khanal4 1
Clinical Education, University of Adelaide, 3Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia, 2Educational Design and
Support and 4Program Evaluation, NPS MedicineWise, Sydney, New South Wales, Australia
Key words prescribing, medical education, medication safety. Correspondence Josephine Thomas, Clinical Education, University of Adelaide, 1-4 Eleanor Harrald building, 50 North Terrace, Adelaide, SA 5000, Australia. Email: [email protected] Received 18 June 2013; accepted 9 October 2013. doi:10.1111/imj.12316
Abstract Background: Attendance at face-to-face sessions and completion of online components of the National Prescribing Curriculum was made compulsory for final year medical students at the University of Adelaide in 2010. Aims: To determine the impact of a compulsory prescribing curriculum for final year medical students on their prescribing competencies at the start of clinical practice. Graduates’ attitudes to their medical school training in prescribing were also surveyed. Methods: Two cohorts of medical graduates from the University of Adelaide who commenced medical practice in 2010 and 2011 were required to complete a prescribing task using the National Inpatient Medication Chart (NIMC) at orientation and after 6 months of clinical practice. The main outcome measure was a performance in a scenario-based prescribing test, as determined by test scores and overall safety of prescriptions at orientation and 6 months of clinical practice. Results: There was a small difference in the average total score for the prescribing task between the 2010 and 2011 cohorts at orientation (P = 0.0007). The 2011 cohort had a higher number of safer charts at commencement of practice. We found no difference between the 2010 and 2011 cohorts in attitudes towards their undergraduate pharmacology education, and new graduates feel poorly prepared. Conclusion: Medical graduates who are required to complete a practically oriented prescribing curriculum in final year perform slightly better on a prescribing assessment at commencement of practice. More work on preparing graduates for this complex task before graduation is needed.
Introduction Deficiencies in the ability of junior doctors to prescribe safely and adequately for hospital inpatients have been highlighted in the medical literature.1,2 Prescribing medications is a critical part of medical practice and begins from the first day of practice. While many of the prescribing errors are attributed to the work environment and junior doctor workload, some authors have highlighted the inability of medical curricula to prepare junior doctors for this task.3–5 Junior doctors themselves cite deficiencies in their training as a contributor to their inadequate prescribing skills.5,6 The National Prescribing Curriculum (NPC) (http:// www.nps.org.au/npc) was developed by NPS MedicineWise (formerly known as the National Prescribing Service) in collaboration with the Australasian
Funding: None. Conflict of interest: None.
156
Society of Clinical and Experimental Pharmacologists and Toxicologists and was made available to all Australian medical schools in 2001.7 The University of Adelaide Medical School utilises the NPC7 in the final year of a 6-year undergraduate medical curriculum. The University of Adelaide programme consists of 10 face-to-face tutorials with a clinical pharmacologist to complement the online modules. Following completion of each module, a face-to-face tutorial session is held where the students can ask questions to clarify and further expand on the work they have completed online. These prescribing sessions integrate well with previous elements of the University of Adelaide medical school curriculum, which provide basic clinical pharmacological and pharmacotherapy concepts. Previously, the uptake of the prescribing curriculum at the University of Adelaide was very poor, with attendance as low as 25% in some sessions. To enhance the prescribing skills of all medical graduates, the sixth year prescribing curriculum was made a compulsory element for final year students from January 2010. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
Prescribing curriculum study
As a large proportion of University of Adelaide graduates choose to undertake their internship at the Royal Adelaide Hospital (RAH), the transition of the prescribing curriculum from optional to compulsory offered a unique opportunity to evaluate the impact of completing the course in the prescribing competencies of new graduates.
Methods Study design This study aimed to evaluate new graduates’ competency in prescribing and to compare the effect of completing a compulsory prescribing curriculum. All interns commencing duty at the Royal Adelaide Hospital in January 2010 and 2011 were given a prescribing task during their orientation programme. A survey was also conducted to obtain the graduates’ views on the undergraduate prescribing curriculum. In January 2010, final year medical students at the University of Adelaide were required to complete the NPC online modules and attend at least 95% of the face-to-face tutorials. Failure to complete the programme was a barrier to graduation; these students formed the 2011 cohort. Interns who were graduates of the University of Adelaide thus formed a control (2010 cohort) and intervention (2011 cohort) group for comparison. Although we were only targeting University of Adelaide graduates, all interns were included in the survey to simplify the study process (this was easier than selecting a group). Analysis was then limited to the target group. Ethics approval was obtained from the Royal Adelaide Hospital Ethics Committee, and written consent was obtained from all participants before their inclusion in the study. The task was performed prior to any orientation by the pharmacy or pharmacology departments, and was the same case scenario utilised by Hilmer et al.5 in their study of new graduates at NSW hospitals in 2008. The task was modified slightly from Hilmer’s study (to exclude the discharge prescription component). This was necessary due to changes in the local hospital process for discharge scripts. Study participants were required to write a prescription for the patient on the Australian National Inpatient Medication Chart (NIMC).6 All graduates were supplied with the necessary drug information for the prescribing tasks including the approved product information for each drug related to the case from local resources including Monthly Index of Medical Specialties8 and Australian Medicines Handbook9 monograph, in addition to prescribing guidelines for neutropenic fever from Therapeutic Guidelines,10 and a copy of the NIMC.6 Following 6 months of medical practice, interns were reassessed with the same prescribing task. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
Prescriptions were scored independently by two clinical pharmacologists (JT and SS) according to pre-specified criteria. Discrepancies were reconciled by consensus. One point was awarded for each of the following parameters (total possible marks = 36): • At least two unique patient identifiers recorded (e.g. name and date of birth) • Complete allergies recording • Regular medications charted (for each medication) – one point for each of: date, route, generic name, dose/ frequency, signature/name of prescriber • Slow release box ticked for sustained-release morphine (MS Contin) • Paracetamol charted (as needed or regular) – one point for each of: date, generic name, route, dose/frequency, signature/name of prescriber • Ticarcillin with clavulanic acid (Timentin; GlaxoSmithKline, Aspen Pharmacare Australia Pty Limited, Sydney, NSW, Australia) – not charted due to documented penicillin allergy • Gentamicin – not charted (in preference for cefepime as per supplied guidelines) • Additional ‘as needed’ analgesia charted – one point each for: opioid, immediate release, oral route, appropriate dose (equivalent 10–15 mg oral morphine), frequency 2–4 hourly, legal opioid order To add a more realistic measure of competence, charts were also classified as ‘safe, moderately unsafe or severely unsafe’ by JT and SS according to potential to cause harm, based on a standardised method.11 All interns were given general feedback about prescribing performance at the end of orientation; in addition they were offered the option to receive individual feedback on their performance by email.
Statistical analysis Each parameter was given one mark for correct completion, and the total task score was a count of parameters completed correctly. The changes in the average total score from orientation to 6 months in the two cohorts were compared by using a marginal log-linear model using generalised estimating equations (GEE) with a Poisson distribution and a log link function. GEE proportional odds regression, with a multinomial distribution and a cumulative logit link function was used to estimate the odds of the graduates writing safer prescription over the 6-month duration for both cohorts. Graduates’ attitude towards their undergraduate pharmacology education was also compared between the two cohorts. The responses were aggregated to three groups of ‘strongly disagree/disagree’, ‘neutral’ and ‘strongly agree/agree’. Fisher’s exact test was used to assess the 157
Thomas et al.
Table 1 Level of safety of the prescriptions written by interns at orientation and 6 months of their internship Level of safety
Safe Moderately unsafe Severely unsafe
2010 cohort (n = 50)
Table 2 The proportional odds of interns completing a safer chart Total scores
2011 cohort (n = 59)
Orientation (%)
6 months (%)
Orientation (%)
6 months (%)
13 (26.0) 14 (28.0) 23 (46.0)
25 (50.0) 17 (34.0) 8 (16.0)
22 (37.3) 15 (25.4) 22 (37.3)
39 (66.1) 16 (27.1) 4 (6.8)
association between the two cohorts and graduates’ attitude. Results were considered statistically significant if P-value < 0.05. The analyses were carried out with the use of statistical analysis software SAS version 9.13 (SAS Institute Inc., Cary, NC, USA).
At orientation 2011 cohort vs 2010 cohort 2010 cohort 6 months vs orientation 2011 cohort 6 months vs orientation After 6 months practice 2011 cohort vs 2010 cohort
Odds ratio
95% CI
P-value
1.59
0.77–3.29
0.21
3.40
1.54–7.51
0.002
4.13
2.01–8.49
