How prepared are medical graduates to begin prescribing?

As almost all inpatients and about half of all general practice consultations require a prescription, it is essential that drugs are prescribed effectively, safely and on the basis of an understanding of the principles of pharmacology and therapeutics. In the past, prescribing has been perceived as a skill that could be acquired on the job, as have managing workload, being on call and performing clinical procedures. However, most medical graduates are under-prepared for prescribing, both in terms of the underpinning pharmacological knowledge, and the practical elements, such as calculating dosages, or writing up an inpatient medication chart or discharge script.1–4 New graduates are required to prescribe many times each day in the medication chart, which often includes initiation of high-risk therapies, such as anticoagulation, insulin and opioid analgesics. Demands have increased because of an increased number of drugs per patient, higher patient throughput, older patients with more co-morbidities and more complicated regimens. Prescribing errors are common and are more likely to occur in the first year after graduation than in all other years.5–7 A recent symposium emphasized the importance of education as the cornerstone in improving prescribing and recommended enhanced pharmacology and therapeutics training for medical students.8 Prescribing is a core skill which should be taught to every medical student and their competency assessed before they are allowed to prescribe to sick patients from day one of their internship. It is no longer acceptable to assume interns will pick up these skills as they go, or that it is safe because they are supervised in a teaching hospital. In reality, scripts are seldom checked by their medical superiors. In studies of prescribing errors in hospital, inadequate supervision is an important factor, yet students expect to be given instructions and to be contacted if they make mistakes.9 The novice's lack of understanding of the complexities of prescribing does not appear to be appreciated or addressed by supervisors. An exception is where interns work in hospitals with a ward pharmacist service. By checking medication charts, experienced clinical pharmacists can play a key role in the defences against prescribing error.10 Unfortunately, not all interns work in clinical areas with such a pharmacist and where they do, pharmacists are not available all of the time. With the international move to changes in curriculum design away from didactic learning and towards an integrated problem-based approach, some of the more traditional learning of pharmacology has been lost with nothing to replace it. Studies in recent medical graduates and interns both in Australia and abroad have identified that undergraduate training in clinical pharmacology and therapeutics is insufficient to prescribe safely and rationally, and prescribing is one of the most frequently identified medical school learning needs.1,9,11–14 The article by Hilmer et al.15 in this issue of the Journal, based on a cross-sectional study conducted at four New South Whales hospitals in January 2008, provides further evidence that medical graduates are not adequately prepared for safe and effective prescribing. While the primary finding was of significant deficits in prescribing, graduates indicated that they would have liked more clinical pharmacology training at medical school. Most did not feel their pharmacology training was equivalent to training in other medical disciplines and the area they felt least prepared for was prescribing. It would have been useful to have had a second assessment after orientation. However, while intern orientation week provides an invaluable opportunity to start getting graduates up to speed for medical practice, it is too late to start learning the complexities of prescribing. This must be adequately covered during their undergraduate training, with the few extra hours during orientation acting as revision/re-enforcement. It would also have been interesting to compare the performance of those who had previously worked through the National Prescribing Service (NPS) modules,16 with those who had not. In 1997 the NPS was created to implement the national Quality Use of Medicines programme, the fourth arm of the Australian National Medicine's Policy.17 One of the highest priorities identified in a nationwide survey to identify priority areas for the NPS was given to improving the quality of prescribing education. A web-based interactive programme comprising a set of modules was developed, with representation from all major medical schools throughout Australia at the time.16 The modules are based on therapeutic topics that interns identified as most important to them in their first year of clinical practice, each placing emphasis on particular aspects of prescribing. The programme, designed to inculcate an evidence-based approach to prescribing, is available free of charge to all medical schools and their students. Unfortunately, it appears that some schools have not capitalized on this resource and have not included it as a core component of their clinical pharmacology curricula. Clearly prescribing competency should be examinable and might include the learning outcomes in the NPS modules. Until this is the case, many students may consider that prescribing proficiency is a low priority and may not have the incentive to work through the modules. Students at the University of Queensland Medical School are now exposed to the practicalities of prescribing during their training. A series of eight interactive problem-based tutorials, each lasting 90 min, has become a component of the medical curriculum.18 The programme has recently been adopted by Griffith and James Cook Universities. The sessions, facilitated by experienced clinicians, pharmacists and occasionally nurses, are designed to increase the ability of medical students to prescribe safely in commonly encountered situations. Students also learn about safe medication management and the importance of the interactive role of medical, pharmacy and nursing staff in ensuring safe and effective drug use. Teaching prescribing has become increasingly difficult, as drug therapy has become more complex and errors more common. Clearly it is the responsibility of medical schools to provide many more hours of clinical pharmacology teaching, paying particular attention to the core skill of prescribing. Drugs are the major therapeutic intervention provided by most doctors throughout their careers. Prescribing is a high-risk intervention and prescribing skills and awareness of medication errors must be emphasized more than in the past.19 It is time for a cultural shift in which prescribing is seen as a core skill and an essential component of undergraduate training programmes. A reappraisal is required of how learning about drugs occurs and should prompt a re-examination of where in the curriculum such practical skills can be gained. Medical schools should have robust assessment structures of prescribing competence and consideration should be given to the sharing of best practice and learning materials in this area. Medical students have said that not enough time is devoted to teaching pharmacology and prescribing. Our prescription should be to expose them to more. I wish to thank Associate Professor Charles Mitchell (Department of Medicine, University of Queensland) for his useful editorial comments.