Prescribing Competency among Final Year Medical Students

PRESCRIBING COMPETENCY AMONG FINAL YEAR MEDICAL STUDENTS AND PERCEIVED FACTORS ASSOCIATED WITH IT

STATEMENT OF PURPOSE

Rational prescribing is a daunting task; it requires adequate knowledge and skill in Clinical Pharmacology and Therapeutics and its appropriate application within a clinical context (1). Prescribing errors is one of the major causes of unintended harm to patients and can compromise their safety (2). Thus, it may result in poor patient outcome, hospitalization and even death (2,3).

Prescribing faults and prescription errors are increasingly common-place; they are an unfortunate reality of our healthcare practices and can range from trivial mistakes to potentially serious outcomes (4-6). Prescribing is a multi-staged process that involves decision-making about therapeutic options, relaying appropriate information to patients, and dispensing, administering and monitoring of medication; errors or faults can happen at any stage (7).

Studies have shown that 15 to 21% prescriptions contain one or more prescribing errors (8). Reports from UK study reveal that 15% of the 21,589 new prescriptions, written over a 4-week period in 24 critical care units, contained at least one prescribing error and an estimated 19.6% of these errors were regarded as life-threatening (7).

Young medical graduates are generally responsible for the majority of hospital prescriptions (9). Studies have indicated that these new doctors write 68% of hospital prescriptions and are responsible for an estimated 10% prescribing errors in their first two years of clinical practice (2). Findings from a London teaching hospital revealed an estimated 135 prescribing errors made per week, a quarter of which were potentially serious; the majority of these errors were made by house officers (9).

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Research findings suggest that most prescribing errors in clinical practice can be attributed to insufficient prescribing competency among final year medical students (10). Evidence gathered from various studies reveal a general lack of readiness among future medical professionals; students reported that their medical education had left them unprepared for the responsibility of rational prescribing (10,11).  Studies indicated that students suffered from poor self-confidence, and had inadequate prescribing competency and proficiency in areas such as pharmacovigilance, drug dosage, first-line treatments for chronic illness, and local prevalence of bacterial resistance (2).

These findings corroborate the possibility that undergraduate medical education requires restructuring. The absence of a distinct course in clinical pharmacology and therapeutics has left students ill-prepared for such an integral medical practice (12,13). An analysis of 88 serious medication errors in a British teaching hospital, by Dean and associates (2002), revealed that poor skills and knowledge proved an instrumental factor in 60% of cases (14).

Other than the structure and content of the medical curriculum, student body number, their personality, clinical placement, exposure and shadowing also influence their prescribing competency (15). Increased workload, lack of standardization and polypharmacy are other factors in inadequate and irrational prescribing practices. However, inadequate education and training remains a major contributory factor (10).

Considerable evidence from European and Australian studies has established a widespread belief that final year medical students have inadequate prescribing competence (2,10,11). However, there is a paucity of literature to support these findings among final year medical students in Pakistan. This study is an attempt to highlight the capabilities of our final year medical students in prescribing medications. Also, to determine whether they have adequate crucial prescribing competence, as assessed by their knowledge and skills in Clinical Pharmacology and Therapeutics, and the ability to identify factors associated with inadequacy in prescribing medications.

JUSTIFICATION

Pharmacology is taught as an integrated course in system-based modules at Aga Khan University (AKU), Karachi, Pakistan. Essential knowledge and skills are communicated to medical students via lectures, problem-based learning (PBLs) and self-directed learning. This approach at AKU is similar to many across the globe. However, this method comes with its own setbacks such as a lack of efficient sign-posting which can lead to a poor awareness of teaching and learning of concepts in clinical therapeutics (16). This is supported by findings from UK medical schools which reveal that less than 20% of their medical graduate recall having taken a distinct clinical pharmacology course (9). In fact, many interns or junior doctors opined that poor emphasis was laid on the clinical aspects of prescribing during their medical education (16).

Furthermore, O’Shaughnessy et al (2010) reports that while most UK medical schools consider their student to be adequately prepared for the clinical aspects of prescribing; in reality only 37% of schools actually assess their students’ competency (17). In Pakistan, there is a lack of comprehensive overview of the prescribing competency of graduating medical students as well as limited high-quality studies on prescribing errors in the country. A study from Lahore showed that 39.28% of total prescribed medications had prescribing errors while another study from a hospital in Hyderabad revealed that most written prescription did not follow proper guidelines (18,19).

Limited information on rational use of medications accentuates the need to not only evaluate the prescribing competence of graduating students in Pakistan but also to identify perceived factors responsible for any deficits in this area. This is particularly important if we need to determine whether our fresh graduates have been adequately prepared to satisfy the patients’ need and meet the quality bar of professional ethics.

The data or findings gathered from this study can be used to formulate suggestions and/or recommendations for governing bodies, academicians, health professionals and policy makers to revisit the current national medical curriculum to better prepare quality medical graduates.

BACKGROUND

Prescribing is often misunderstood as solely an act of prescription writing. While a common medical practice, it is a high-risk intervention designed to improve patient healthcare (8,9).

Medication errors are an obstacle in providing optimum patient care; prescribing errors and faults account for 70% of all medication errors (5,8). According to a review, prescribing errors occur in about 7% of hospital prescriptions, 2% of patient days, and 50% of hospital admissions (10).

Statistics confirm that young doctors are two times more likely than consultants to cause prescribing errors (10). Research revealed that students lack both confidence and competency in executing prescribing skills unlike other aspects of clinical practice such as history taking or physical education (10,11). Many recent graduates perceive that this can be attributed, in part, to a lack of emphasis placed on this critical proficiency during their medical education (16).

This growing incompetence may also be explained by the inadequacy of the structure of medical curriculum. This has been established by findings from a cross-sectional European study where students taught with the aid of problem-based learning, in clinical pharmacology, fared better than their counterparts undergoing traditional learning (10).

Furthermore, proficiency in prescribing has, traditionally, been acquired through practical experience in clinical attachments. However, this method has been found lacking. It has been argued that students should not be required to “pick things on the job” as they ease into clinical practice. Rather, training as novice prescribers should be begun as medical students when there is less time-pressure and better supervision (16).

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There is limited literature available on the prescribing competence of graduating medical students in Pakistan. A study in Lahore assessing the prescribing skills of House-officers at King Edward Medical College reports that participants felt inadequately prepared for the task (20). The present study is an attempt to verify the prescribing proficiency of final year medical students in Karachi and to ascertain perceived shortcomings that could explain this deficiency.

OBJECTIVES

1. General
   1. Evaluate the knowledge and skills of final year medical students, in Karachi, with regards to their prescribing competency and the perceived causes of deficiency associated with it
2. Specific
   1. Determine the depth and accuracy of knowledge in essential Clinical Pharmacology and Therapeutics of final year medical students, in Karachi
   2. Evaluate the prescribing skills, using clinical case scenarios, of final year medical students, in Karachi
   3. Identify the perceived causes of deficiency in knowledge and skill of final year medical students, in Karachi

REFERENCES

1. Mucklow, J., Bollington, L., & Maxwell, S. (2011). Assessing prescribing competence. British journal of clinical pharmacology, 74(4), 632-9.
2. Brinkman, D. J., Tichelaar, J., Graaf, S., Otten, R. H. J., Richir, M. C., and van Agtmael, M. A. (2018) Do final‐year medical students have sufficient prescribing competencies? A systematic literature review. Br J Clin Pharmacol, 84: 615–635. doi: 10.1111/bcp.13491
3. Kamarudin G, Penm J, Chaar B, et al. Educational interventions to improve prescribing competency: a systematic review. BMJ Open 2013;3:e003291. doi: 10.1136/bmjopen-2013-003291
4. RamaKrishna, M., Divya, G., Lakshmi, P., Kannan, MM and Ranganayakulu D. (2014). Common prescribing errors in Government general hospital. Interational Journal of Research in Pharmacy and Science, 4(4): 27-31
5. Velo, G. P. and Minuz, P. (2009), Medication errors: prescribing faults and prescription errors. British Journal of Clinical Pharmacology, 67: 624-628. doi:10.1111/j.1365-2125.2009.03425.x
6. Ryan, C., Ross, S., Davey, P., Duncan, E. M., Francis, J. J., Johnston, M., . . . Bond, C. (2014, January 3). Prevalence and Causes of Prescribing Errors: The Prescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0079802#s4
7. Ridley, S. A., Booth, S. A., Thompson, C. M. and, (2004), Prescription errors in UK critical care units. Anaesthesia, 59: 1193-1200. doi:10.1111/j.1365-2044.2004.03969.x
8. Mohan, P., A. K., & Panwar, S. S. (2014). Identification and quantification of prescription errors. Medical Journal of Armed Forces India, 70(2): 149-153. Retrieved from https://www.sciencedirect.com/science/article/pii/S0377123714000227?via=ihub
9. Heaton, A. , Webb, D. J. and Maxwell, S. R. (2008), Undergraduate preparation for prescribing: the views of 2413 UK medical students and recent graduates. British Journal of Clinical Pharmacology, 66: 128-134. doi:10.1111/j.1365-2125.2008.03197.x
10. Brinkman, D. J., Tichelaar, J., Schutte, T., Benemei, S., Böttiger, Y., Chamontin, B., . . . Wilson, K., Vries, T., Richir, M. C., Agtmael, M. V., Working Group Research on CPT Education of the European Association for Clinical Pharmacology and Therapeutics (EACPT) (2016). Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students. Clinical pharmacology and therapeutics, 101(2), 281-289.
11. Kemp, L. K., Mangoni, A. A., & Woodman, R. J. (2014). Online survey on subjective and objective competency in clinical pharmacology skills among final year Australian medical students: a pilot study. Therapeutic advances in chronic disease, 5(6), 274-9.
12. Patrício, K., Alves, N., Arenales, N. and Queluz, T. (2012). Teaching the Rational Use of Medicinesto medical students: a qualitative research
13. Garbutt, J. M., DeFer, T. M., Highstein, G., McNaughton, C., Milligan, P., & Fraser, V. F. (2006). Safe prescribing: An educational intervention for medical students. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16776613
14. Dean, B., Schachter, M., Vincent, C., & Barber, N. (2002, April 20). Causes of prescribing errors in hospital inpatients: A prospective study. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11978334/
15. Illing, J., Kergon, G., Burford, C., Spencer, B., Davies, J., Baldauf, C. et al. (2008) How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. London: General Medical Council
16. Ross, S. and Maxwell, S. (2012), Prescribing and the core curriculum for tomorrow’s doctors: BPS curriculum in clinical pharmacology and prescribing for medical students. British Journal of Clinical Pharmacology, 74: 644-661. doi:10.1111/j.1365-2125.2012.04186.x
17. O’Shaughnessy, L. , Haq, I. , Maxwell, S. and Llewelyn, M. (2010), Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009. British Journal of Clinical Pharmacology, 70: 143-148. doi:10.1111/j.1365-2125.2010.03665.x
18. Shawahna R, Rahman NU (2008). Prescribing errors in psychiatry department: An audit from a hospital in Lahore, Journal of Pakistan Psychiatric Society, Audit article page 31.
19. Saleem, R., Dayo, A., Ghoto, M. and Akram, M. (2013) Prescription writing error in general practice: A cross sectional study at tertiary care hospital in Hyderabad, Pakistan. Journal of Pharmacology and Biological Sciences.
20. Azeem, M., Bhutta, A.R., Bashir, A., Pervez, A., Samee, U., Raza, A. (2010). Are King Edward Medical University Graduates Adequately Trained to Prescribe Medicine at the Point of Graduation? Views of House Officers. Pakistan Journal of Medical and Health Sciences.