CONTINUITY IN MEDICAL EDUCATION
Teaching Practical Prescribing and Therapeutics Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
ANDREW HERXHEIMER Andrew Herxheimer, MB, BS, FRCP, is Senior Lecturer in Clinical Pharmacology and Therapeutics, Charing Cross Hospital Medical School, London, UK, and Editor of the Drug and Therapeutics Bulletin. As noted in our editorial in the last issue, continuity in medical education was the subject of a conference organized by the Association of Medical Education, and held in London in June 1982. One of the keynote speakers was Dr Andrew Herxheimer, whose contribution on teaching practical prescribing and therapeutics is printed below, Some will claim that the approach advocated by Dr Herxheimer is already being attempted, while others will wonder how such an increase in the competence of undergraduates is to be achieved in a n already overcrowded curriculum. The paper should, at least, lead to discussion. Dr Herxheimer’s paper is followed by a description of the Open University course ‘Topics in Drug Therapy’ (P550), made for the Council for Postgraduate Medical Education in England and Wales and launched in October 1982. I t is aimed at all practising doctors, especially trainees and general practitioners.
Figure 1. Dtflerences between undergraduates and doctors Undergraduate Responsibility for treatment and for explaining it Experience
none
Oshared or full
@small and
scattered 0 as
Opportunities to contribute creatively (new knowledge, insights)
Postgraduate
spectator
0 exceptional
0 widening,
deepening, specializing as prescriber universal
B explain these decisions to colleagues and to patients;
Undergraduate teaching aims to provide the scientific foundations, the basic intellectual skills and the attitudes that will be needed to develop a good style of practice. Postgraduate teaching aims to relate these to the student’s experience as an increasingly autonomous prescriber, to help him or her develop a rational and coherent system of working which can be adapted to the changing needs of practice during the doctor’s professional lifetime. Knowledge is deepened and refined, judgement and discrimination are sharpened, practical skills are acquired, and sound attitudes are tested and more securely anchored. Aims and the Balance of Teaching Before we can consider what should be taught at each stage we must decide what we require from the fully independent doctor. Briefly, a fully trained doctor should be able to make rational decisions about prescribing and therapy, giving due consideration to efficacy, safety, convenience, and cost. He or she should be able to: 16
formulate treatment policies; search out the relevant information about drugs and other treatments; assess reports of relevant clinical trials; assess claims made by colleagues (specialist or not) and pharmaceutical companies. Which of the ingredients needed for these abilities should we try to teach undergraduates? In choosing the menu we have to be influenced by the substantial differences between undergraduates and doctors in terms of responsibility, experience and opportunity as indicated in Figure 1. Undergraduate Curriculum
I suggest the undergraduates should learn: 0 to take a treatment history. 0 to read and understand prescriptions for in- and outpatients. Medical Teacher Vol 5 No I 1983
Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
0 to use approved names wherever possible (but to understand that formulations of the same drug may differ). 0 the types of information needed for proper use of a drug, how to look it up in appropriate sources, and how to use it. 0 what the patient should know or understand about his medication. 0 the rationale of symptomatic treatment of common symptoms; when not to prescribe; the choice of remedies; how to write a suitable prescription. 0 to identify a patient’s therapeutic problems and formulate short- and long-term treatment plans. to write a succinct critical summary of a patient’s treatment. 0 the management of common conditions/diseases (including self-poisoning and overdosage). when and why measurement of drugs in blood may be useful. about adverse reactions: when to suspect their occurrence, how to investigate the possibility; principles of management; reporting to the Committee on Safety of Medicines prevention. about interactions: evaluation of potential interactions. the effects and uses of placebos, including ethical aspects. about clinical trials: design, performance, ethical aspects, assessing reports, applying the results in practice. about new drugs: discovery, testing in man, licensing, promotion, assessment of claims.
Such a programme should extend throughout the whole length of the clinical course. Postgraduate Curriculum
This undergraduate programme would lead naturally into postgraduate teaching related to: individual specialties; personal experience (prescribing audit, Balint group* work); design of treatment policies in hospital, general practice, etc; record systems for checking prescribing (repeat prescribing, interactions, event monitoring, long-term follow UP); evaluation, design, performance of relevant clinical surveys and trials. This list does not mention a very important aim of postgraduate teaching: to prevent or reduce the deteriora-
‘Balint groups are groups of doctors and/or other health professionals who meet regularly to analyse doctor-patient (or professional-client) relationships. The members aim to deepen understanding and improve their handling of the doctor-patient relationship. They take turns in presenting their cases to the group which has a specially trained leaderoften a psychotherapist or a general practitioner.
Medical Teacher Val 5 No I I983
MAVIS Medical Audio Visual Aids Information Service Do you teach undergraduate medical students? Do you organize postgraduate meetings? Do you teach nurses and other paramedical staff? Are you thinking of producing your own audio visual programmes? Have you thought of using audiovisual programmes for your own continuing education?
. . . then you might find it useful to have a list of all the audiovisual programmes in your area of interest. In the Medical Audio Visual Aids lnformation Service we have indexed over 10,000 programmes from approximately 1,000 catalogues obtained from British universities, societies and institutions, pharmaceutical companies and other commercial companies. If you are interested write for further details to: Mrs S. Bruce Senior Inf or matio n Officer Centre for Medical Education University of Dundee Dundee D D 1 4 H N Tel: 0382-23181 ext 617 This service has received support from Update Publications Ltd and The Wellcome Foundation L td.
17
tion in therapeutic knowledge and skills that seems to affect so many young doctors during the first years after qualification. The lack of an effective educational programme, and even of effective supervision, at this stage undermines the good work done with undergraduates, and impedes what is to follow.
T h e Present and the Future
Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
The division outlined here is of course schematic. It will take many years before all undergraduates will be taught
what I have suggested. Until then the gaps will have to be made good after graduation. We shall always need postgraduate reinforcement and recapitulation of undergraduate material. This is illustrated by the pilot course ‘Topics in Therapeutics’ made by the Open University for the Council for Postgraduate Education in England and Wales. It incorporates much that undergraduates should learn in a form rooted in, and directly relevant to, general practice. However, the spread of the types of postgraduate work outlined is likely to influence the approach of those who teach undergraduates, and may in time make the transition smoother and more gradual.
Topics in Drug Therapy: an Open Universitv Pilot Course for Doctors JANET GALE Janet Gale, The Open Uniue~sity,Institute of Educational Technology, Walton Hall, Milton Keynes, MK7 6AA, UK.
The Health and Social Welfare Section of the Open University provides continuing education courses designed mainly for professionals, paraprofessionals and voluntary workers in the fields of health, education and social welfare Topics in Drug Therapy is the Open University’s first course intended for doctors, and is a pilot project funded by the DHSS and made in collaboration with the Council for Postgraduate Medical Education in England and Wales. It combines the technological and educational expertise of the Open University with the clinical and academic expertise of 11 course team members from the medical profession and a large and varied group of doctors who tested the course at various stages in its development. For the pilot course, three topics were selected from an original plan to produce an eight-topic course. This paper outlines the course structure, content and intended manner of use, the three-stage developmental testing procedure which it underwent, and some of our main findings. The illustrations are taken from the learner’s text (Figures 1-3). Course Structure The course is designed so that individual doctors who wish to study it at home can do so successfully without attending group meetings. Such individuals would receive written course texts and an audiocassette but would not normally have access to videocassette material, which is distributed only to group leaders who organize the 18
group sessions (for example, vocational trainer or course organizer, clinical tutor, peer group leader) and is intended for use at group sessions only. There will be no broadcast component. People who attend group sessions will study the same course as the individual learners between each group meeting but will also have additional activities, exercises, examples and discussion topics focussed on the videocassette material, which is designed to be fully integrated into the course as a whole. Group sessions, therefore, take up topics and issues raised in the texts and provide the opportunity to consider and clarify these further in the clinical contexts shown on the videocassette and in relation to participants’ own clinical practice and experience. The course lasts for 16 weeks and is run twice a year.
Aims One main aim is to make doctors more aware of the therapeutic choices available to them and of their reasons for prescribing certain drugs. This includes consideration of the social and personal context of drug use, evaluation of the doctors’s own prescriptive use of drugs and the appropriateness and role of alternative non-drug treatments. Thus, another aim is to promote better, more rational prescribing. That is to say, it is boped that participating doctors will consider how to decide on a management plan before reaching for the prescribing pad. O n occasions, doctors may decide not to prescribe a drug at all. If Medical Teacher Vol 5 No I 1983
Teaching Practical Prescribing and Therapeutics Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
ANDREW HERXHEIMER Andrew Herxheimer, MB, BS, FRCP, is Senior Lecturer in Clinical Pharmacology and Therapeutics, Charing Cross Hospital Medical School, London, UK, and Editor of the Drug and Therapeutics Bulletin. As noted in our editorial in the last issue, continuity in medical education was the subject of a conference organized by the Association of Medical Education, and held in London in June 1982. One of the keynote speakers was Dr Andrew Herxheimer, whose contribution on teaching practical prescribing and therapeutics is printed below, Some will claim that the approach advocated by Dr Herxheimer is already being attempted, while others will wonder how such an increase in the competence of undergraduates is to be achieved in a n already overcrowded curriculum. The paper should, at least, lead to discussion. Dr Herxheimer’s paper is followed by a description of the Open University course ‘Topics in Drug Therapy’ (P550), made for the Council for Postgraduate Medical Education in England and Wales and launched in October 1982. I t is aimed at all practising doctors, especially trainees and general practitioners.
Figure 1. Dtflerences between undergraduates and doctors Undergraduate Responsibility for treatment and for explaining it Experience
none
Oshared or full
@small and
scattered 0 as
Opportunities to contribute creatively (new knowledge, insights)
Postgraduate
spectator
0 exceptional
0 widening,
deepening, specializing as prescriber universal
B explain these decisions to colleagues and to patients;
Undergraduate teaching aims to provide the scientific foundations, the basic intellectual skills and the attitudes that will be needed to develop a good style of practice. Postgraduate teaching aims to relate these to the student’s experience as an increasingly autonomous prescriber, to help him or her develop a rational and coherent system of working which can be adapted to the changing needs of practice during the doctor’s professional lifetime. Knowledge is deepened and refined, judgement and discrimination are sharpened, practical skills are acquired, and sound attitudes are tested and more securely anchored. Aims and the Balance of Teaching Before we can consider what should be taught at each stage we must decide what we require from the fully independent doctor. Briefly, a fully trained doctor should be able to make rational decisions about prescribing and therapy, giving due consideration to efficacy, safety, convenience, and cost. He or she should be able to: 16
formulate treatment policies; search out the relevant information about drugs and other treatments; assess reports of relevant clinical trials; assess claims made by colleagues (specialist or not) and pharmaceutical companies. Which of the ingredients needed for these abilities should we try to teach undergraduates? In choosing the menu we have to be influenced by the substantial differences between undergraduates and doctors in terms of responsibility, experience and opportunity as indicated in Figure 1. Undergraduate Curriculum
I suggest the undergraduates should learn: 0 to take a treatment history. 0 to read and understand prescriptions for in- and outpatients. Medical Teacher Vol 5 No I 1983
Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
0 to use approved names wherever possible (but to understand that formulations of the same drug may differ). 0 the types of information needed for proper use of a drug, how to look it up in appropriate sources, and how to use it. 0 what the patient should know or understand about his medication. 0 the rationale of symptomatic treatment of common symptoms; when not to prescribe; the choice of remedies; how to write a suitable prescription. 0 to identify a patient’s therapeutic problems and formulate short- and long-term treatment plans. to write a succinct critical summary of a patient’s treatment. 0 the management of common conditions/diseases (including self-poisoning and overdosage). when and why measurement of drugs in blood may be useful. about adverse reactions: when to suspect their occurrence, how to investigate the possibility; principles of management; reporting to the Committee on Safety of Medicines prevention. about interactions: evaluation of potential interactions. the effects and uses of placebos, including ethical aspects. about clinical trials: design, performance, ethical aspects, assessing reports, applying the results in practice. about new drugs: discovery, testing in man, licensing, promotion, assessment of claims.
Such a programme should extend throughout the whole length of the clinical course. Postgraduate Curriculum
This undergraduate programme would lead naturally into postgraduate teaching related to: individual specialties; personal experience (prescribing audit, Balint group* work); design of treatment policies in hospital, general practice, etc; record systems for checking prescribing (repeat prescribing, interactions, event monitoring, long-term follow UP); evaluation, design, performance of relevant clinical surveys and trials. This list does not mention a very important aim of postgraduate teaching: to prevent or reduce the deteriora-
‘Balint groups are groups of doctors and/or other health professionals who meet regularly to analyse doctor-patient (or professional-client) relationships. The members aim to deepen understanding and improve their handling of the doctor-patient relationship. They take turns in presenting their cases to the group which has a specially trained leaderoften a psychotherapist or a general practitioner.
Medical Teacher Val 5 No I I983
MAVIS Medical Audio Visual Aids Information Service Do you teach undergraduate medical students? Do you organize postgraduate meetings? Do you teach nurses and other paramedical staff? Are you thinking of producing your own audio visual programmes? Have you thought of using audiovisual programmes for your own continuing education?
. . . then you might find it useful to have a list of all the audiovisual programmes in your area of interest. In the Medical Audio Visual Aids lnformation Service we have indexed over 10,000 programmes from approximately 1,000 catalogues obtained from British universities, societies and institutions, pharmaceutical companies and other commercial companies. If you are interested write for further details to: Mrs S. Bruce Senior Inf or matio n Officer Centre for Medical Education University of Dundee Dundee D D 1 4 H N Tel: 0382-23181 ext 617 This service has received support from Update Publications Ltd and The Wellcome Foundation L td.
17
tion in therapeutic knowledge and skills that seems to affect so many young doctors during the first years after qualification. The lack of an effective educational programme, and even of effective supervision, at this stage undermines the good work done with undergraduates, and impedes what is to follow.
T h e Present and the Future
Med Teach Downloaded from informahealthcare.com by York University Libraries on 01/01/15 For personal use only.
The division outlined here is of course schematic. It will take many years before all undergraduates will be taught
what I have suggested. Until then the gaps will have to be made good after graduation. We shall always need postgraduate reinforcement and recapitulation of undergraduate material. This is illustrated by the pilot course ‘Topics in Therapeutics’ made by the Open University for the Council for Postgraduate Education in England and Wales. It incorporates much that undergraduates should learn in a form rooted in, and directly relevant to, general practice. However, the spread of the types of postgraduate work outlined is likely to influence the approach of those who teach undergraduates, and may in time make the transition smoother and more gradual.
Topics in Drug Therapy: an Open Universitv Pilot Course for Doctors JANET GALE Janet Gale, The Open Uniue~sity,Institute of Educational Technology, Walton Hall, Milton Keynes, MK7 6AA, UK.
The Health and Social Welfare Section of the Open University provides continuing education courses designed mainly for professionals, paraprofessionals and voluntary workers in the fields of health, education and social welfare Topics in Drug Therapy is the Open University’s first course intended for doctors, and is a pilot project funded by the DHSS and made in collaboration with the Council for Postgraduate Medical Education in England and Wales. It combines the technological and educational expertise of the Open University with the clinical and academic expertise of 11 course team members from the medical profession and a large and varied group of doctors who tested the course at various stages in its development. For the pilot course, three topics were selected from an original plan to produce an eight-topic course. This paper outlines the course structure, content and intended manner of use, the three-stage developmental testing procedure which it underwent, and some of our main findings. The illustrations are taken from the learner’s text (Figures 1-3). Course Structure The course is designed so that individual doctors who wish to study it at home can do so successfully without attending group meetings. Such individuals would receive written course texts and an audiocassette but would not normally have access to videocassette material, which is distributed only to group leaders who organize the 18
group sessions (for example, vocational trainer or course organizer, clinical tutor, peer group leader) and is intended for use at group sessions only. There will be no broadcast component. People who attend group sessions will study the same course as the individual learners between each group meeting but will also have additional activities, exercises, examples and discussion topics focussed on the videocassette material, which is designed to be fully integrated into the course as a whole. Group sessions, therefore, take up topics and issues raised in the texts and provide the opportunity to consider and clarify these further in the clinical contexts shown on the videocassette and in relation to participants’ own clinical practice and experience. The course lasts for 16 weeks and is run twice a year.
Aims One main aim is to make doctors more aware of the therapeutic choices available to them and of their reasons for prescribing certain drugs. This includes consideration of the social and personal context of drug use, evaluation of the doctors’s own prescriptive use of drugs and the appropriateness and role of alternative non-drug treatments. Thus, another aim is to promote better, more rational prescribing. That is to say, it is boped that participating doctors will consider how to decide on a management plan before reaching for the prescribing pad. O n occasions, doctors may decide not to prescribe a drug at all. If Medical Teacher Vol 5 No I 1983
