Prescribing

Junior doctor-led practical prescribing course Patrick Haslam, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK Christopher Yau, North Bristol NHS Foundation Trust, Bristol, UK Charlotte Rutter, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

SUMMARY Background: Several authors have studied the transition from medical student to junior doctor. There have been several problems identified, one being prescribing. Junior doctors have been found to be the cause of most of the prescription errors in hospitals. These authors suggest improvements in prescribing teaching, and several describe their own innovations seeking to correct these problems. Context: As junior doctors in a district general hospital in the UK we had the opportunity to provide teaching to small groups

of final-year medical students. We had recently begun working as Foundation Year 1 doctors, and had fresh experience of the transition from medical student and the problems that we had encountered with prescribing. We were acutely aware of the commonly made mistakes. Innovation: We have designed a short, five-session course covering the practical aspects of prescribing. Assuming that theory had been covered elsewhere, we focused on encouraging the students to prescribe on real drugs charts using information available to junior doctors on the

wards. We measured the efficacy of the course by asking the students to rate their own confidence in prescribing in each of the scenarios before and after the session. Implications: The intention was to design and deliver a course that would bridge the gap between pharmacological theory and prescribing in practice. Existing prescribing courses are often taught by senior doctors or pharmacists. We believe that the major strength of this course was that it was designed and delivered by junior doctors, under the supervision of a senior doctor.

Junior doctors have been found to be the cause of most prescription errors in hospitals

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Prescribing has been an area in which students feel inadequately taught

INTRODUCTION

T

he transition from medical student to junior doctor is an aspect of training that has often been overlooked in the past; however, the profession has become increasingly aware that this key stage needs developing to ensure that new graduates are competent in the everyday tasks required of them whilst working on the wards. Several authors have found that medical students and recent graduates feel unprepared for their role as a junior doctor.1–3 In particular, prescribing has been an area in which students feel inadequately taught. One recent survey of 100 graduates found that only 32 per cent considered themselves competent to prescribe.2 It is unsurprising, therefore, that this has had serious consequences, with one study noting that junior doctors commit 84 per cent of prescribing errors.4 The nature, and cause, of these errors is complex. Dean et al. interviewed doctors who had committed various errors, and several causes were identified.5 These included a lack of knowledge, inadequate training and an absence of self-awareness of errors. They suggested teaching junior doctors about the principles of drug dosing and situations in which they are likely to make errors, as well as other interventions.

There have already been several suggestions to correct this gap in undergraduate teaching: a systematic review by Ross et al. has highlighted several, but also noted the lack of strong evidence in this area.6 The exception being the World Health Organization’s Good Prescribing Guide, which has proven efficacy in improving prescribing. Combes et al. outlined a successful prescribing course that they instituted covering theoretical and practical aspects, which was delivered by pharmacists, nurses and senior

doctors.7 Scobie et al. also outlined a course facilitated by pharmacists, covering various clinical and prescribing skills, which successfully improved students’ scores in objective structured clinical examinations (OSCEs). Kavanagh et al. suggested that more experiential learning should be used in the teaching of drug prescribing by using simulation.9 This was also noted by Ross et al., stating that teaching should use ‘simulated real-life practice involving the completion of actual prescriptions for undergraduates where possible’.6

CONTEXT Following graduation we started work as Foundation Year 1 (FY1) doctors in a district general hospital (DGH) in the South West of England, and felt underprepared when it came to the practicalities of medication prescribing. A short period of shadowing helped, but could not make up for the lack of teaching as undergraduates. We followed a steep learning curve over the initial months, in terms of our prescribing skills, by learning on the job. It was clear that our undergraduate education had illprepared us for work as prescribers; however, we felt that it was not the theory behind medications but rather the knowledge of how to prescribe practically in the hospital ward setting that was lacking. The DGH in which we worked offered clinical placements to final-year medical students; this offered us the opportunity to provide some relevant teaching. We felt that we could write and deliver a short course in prescribing for the final-year students to prepare them for work as a junior doctor. As recent graduates we were acutely aware of the deficiencies in our practice, and the mistakes made by us were common to all our peers. The intention was to design and deliver a course that would

bridge the gap between pharmacological theory and prescribing in practice.

INNOVATION We designed a five-session course aimed at final-year medical students, comprising of small group learning and discussion. The aim of the course was in two parts: first, to address practical aspects of prescribing, which we felt were poorly taught in medical school; and second, to cover common topics most relevant to junior doctors when working on the wards. The clinical scenarios are outlined in Box 1. These subjects were not just based on the five most common presentations or pathologies faced by junior doctors. We chose these scenarios based on two factors: what scenarios did we most commonly prescribe for, and which scenarios would give us the best opportunity to cover different prescribing techniques. The first session on acute coronary syndrome allowed us to cover the basics of once only, regular and ‘as required’ prescribing, but it is also a common scenario for a junior doctor to face whilst on-call or on a medical admission unit. For each session the students were given blank drug charts and copies of the British National Formulary (BNF). After introducing each scenario, the students were then asked to prescribe the appropriate medication on the drug charts provided. We were keen to initially let the students make an attempt without too much assistance, followed by a

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facilitated discussion. This encouraged student interaction and corrected any misunderstandings. An important assumption was that the students knew the theory behind the medications: the aim of the course was to teach them how the medications were prescribed rather than how they worked. In the scenario where we went through prescribing Warfarin, the students were happy to explain the mechanism of action of Warfarin, but had never been through the process of anticoagulating a patient. Over the five sessions we covered a broad range of skills and scenarios, at each point highlighting commonly made mistakes. In order to measure the success of the course we would have liked to ask the students to sit a formal test before and after the course; however, because of time constraints this was not possible, and so we collected feedback forms following each session. These forms included space for comments on good and bad points, and suggestions for improvement. Comments left on the feedback forms can be found in Box 2. We also asked the students to rate their confidence in prescribing for the various scenarios before and after the scenario (0, not confident at all; 10, very confident). Without testing their prior knowledge, we felt that this allowed us to assess how the students perceived their ability to prescribe in these scenarios. Over the duration of the course we saw an average pre-session score of 3/10 rise to 7/10 after the course. The most successful session was on anticoagulation (the average score rose from 2.2 to 7.6), and the least successful was on fluids (the average score rose from 2.5 to 5.4).

and so these were made available and received good feedback. The negative feedback was mainly centred around the fact that the students felt there was not enough time go through the scenarios in enough detail. The next time we ran the session we adapted the scenarios so that

An important assumption was that the students knew the theory behind the medications

Box 1. Session objectives 1 Acute Coronary Syndrome (ACS) • Introduction to the organisation of drug charts • Use of the British National Formulary (BNF) to help prescribing • Basic prescribing of commonly used medications in ACS 2 Antibiotics • Understand the use of trust antimicrobial guidelines • Importance of checking allergies • Learning how to do pre-emptive prescribing • Basic introduction to prescribing Gentamicin, including awareness of taking levels 3 Anticoagulation • Introduction to commonly used anticoagulants • Prescribing and monitoring Warfarin • Ability to treat uncomplicated deep vein thrombosis and pulmonary embolism (DVT/PE) • Ability to manage high International normalised ratios (INRs) 4 Hypo/hyperkalaemia • Management of patients with hypo/hyperkalaemia • Acute management of severe hyperkalaemia • To realise the importance of reviewing existing medication when the clinical context changes 5 Intravenous fluids • Contents of commonly prescribed fluids • Introduce factors involved in fluid prescribing

Box 2. Comments left on feedback forms • Actual drug charts very helpful • Interactive and clear • [It was good] letting us find the drugs in the BNF • [It was good] getting us to actually do it • Good to practise on actual drug charts • Very good. Very useful examples • Excellent course. Good scenarios

The students suggested handouts covering the key points,

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A major strength of our course is that it was devised by FY1 doctors

more time could be spent addressing any issues.

IMPLICATIONS The GMC’s Good Medical Practice document ‘sets out the principles and values on which good medical practice is founded’.10 Providing good clinical care includes prescribing drugs or treatments, and doing this correctly is extremely important from a patient-safety perspective. Some hospitals provide a practical prescribing course given by hospital pharmacists or senior doctors. This ensures accuracy, but does not always reflect the ‘real-life’ situation in which junior doctors find themselves. A major strength of our course is that it was devised by FY1 doctors, and is delivered from their perspective. As well as giving practical teaching on prescribing, the course included tips on how to prescribe whilst on a busy ward cover shift, including how to make the most of opportunities to improve time management and efficiency whilst maintaining good clinical practice. There was also the added benefit of the course being delivered by those who had most recently experienced the transition from medical student to junior doctor. Having found the course well received, we developed the material, with tutor notes, into a regional teaching programme. The material was reviewed by a senior

doctor and then offered to junior doctors working in other trusts within the region. It has been taken up enthusiastically by five trusts within the deanery, and our aim is to review the course materials and feedback at the end of this year, in order to determine whether further improvements can be made. In the future, the aim is that those students who attended the course this year will take over running the course next year, to deliver it to the next cohort of medical students. This can also help with quality assurance and ensure any changes in practice can be incorporated to keep the course up to date and relevant. Ideally, we would like this course to be included within the final-year students’ shadowing block. This would give them a safe environment in which to learn rather than learning ‘on the job’. It would also help to ensure that they are prepared to prescribe practically on their first day of work on the wards. We would also like to quantify how successful the course is by asking students to sit short tests before and after the course, as previously mentioned; however, following feedback from the students we are confident that our course has, in a small way, helped address a gap left in current undergraduate education. REFERENCES 1. Heaton A, Webb DJ, Maxwell SRJ. Undergraduate preparation for

prescribing: the views of 2413 UK medical students and recent graduates. Br J Clin Pharmacol 2008;66:128–134. 2. Han WH, Maxwell SRJ. Are medical students adequately trained to prescribe at the point of graduation? Views of first year foundation doctors. Scott Med J 2006;51:27–32. 3. Wall D, Bolshaw A, Carolan J. From undergraduate medical education to pre-registration house officer year: how prepared are students? Med Teach 2006;28:435–439. 4. Ross S, Bond C, Rothnie H, Thomas S, Macleod MJ. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol 2008;67:629–640. 5. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002;359:1373–1378. 6. Ross S, Loke YK. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 2009;67:662–670. 7. Coombes I, Mitchell C, Stowasser D. Safe medication practice tutorials: a practical approach to preparing prescribers. Clin Teach 2007;4:128–134. 8. Scobie SD, Lawson M, Cavell G, Taylor K, Jackson SHD, Roberts TE. Meeting the challenge of prescribing and administering medicines safely: structured teaching and assessment for final year medical students. Med Educ 2003;37:434–437. 9. Kavanagh P, Boohan M, Savage M, McCluskey D, McKeown P. Evaluation of a Final Year Work-shadowing Attachment. Ulster Med J 2012;81:83–88. 10. General Medical Council. Good Medical Practice. London: General Medical Council; 2006.

Corresponding author’s contact details: Dr Patrick Haslam, General Medicine, Taunton & Somerset NHS Foundation Trust, Musgrove Park Hospital, Taunton, Somerset, TA1 5DA, UK. E-mail: [email protected]

Funding: Funding for some course material was provided by the Postgraduate Academy at Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust. Conflict of interest: The authors have no competing interests. Ethical approval: Ethical approval was not required for this article. doi: 10.1111/tct.12087

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Junior doctor-led practical prescribing course.

Several authors have studied the transition from medical student to junior doctor. There have been several problems identified, one being prescribing...
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