Open University course-Topics in drug therapyJANET GALEMaintenance Course Team Chairperson, Centre for Continuing Education, The Open University.

Topics in drug therapy is the Open University's first course intended for doctors, and is a pilot project funded bythe DHSS and made in collaboration with the Council for Postgraduate Medical Education in England andWales. It combines the technological and educational expertise of the Open University with the clinical andacademic expertise of 11 course team members from the medical profession and a large and varied group ofdoctors who have tested the course at various stages in its development.

THE course consists of a pack of materials to be studiedby each doctor individually, and a group leader's pack of

materials to be used at group meetings. The individual packconsists of a workbook in three short modules with inter-spersed activities and questions, a reference booklet ofsupplementary readings which give specific informationabout drug interaction, modes of delivery and researchfindings, and an audiocassette which has a patient interviewconcerning multiple prescribing and a discussion betweenpartners who had been auditing their prescribing. The groupleader's pack contains notes on running group sessions andgenerally organizing the course for vocational trainees orpeers and a videocassette for use at group meetings.Group meetings have activities, exercises, examples and

discussion topics focused on the videocassette material,which is designed to be fully integrated into the course as a

whole. Group sessions, therefore, take up topics and issuesraised in the texts and provide the opportunity to considerand clarify these further in the clinical contexts shown on

the videocassette and in relation to participants' own clini-cal practice and experience.

Course materials for 'Topics in drug therapy.

Course outlineThe course consists of a first module, introducing partici-pants to background knowledge about drug therapy and to astyle of thinking about treatment that is relevant to drugsgenerally, and two further modules-see panel.

Development of the courseThe course materials went through three stages of develop-ment, drafting and testing:

Firstly, an initial enquiry tested out the idea of the course,

before any draft materials had been produced. Discussionmeetings were held with general practitioner course organiz-ers, regional advisers, vocational trainees and clinical tutorsin four areas of the country, at which plans for Topics in

Journal of the Royal College of General Practitioners, April 1984

Ioul ,.,I-prohlems¢.....amd....iuse ....drug therapffy*The... .s.oci.al context. of presicribing: social and psycho-

lQ4icafactos that affect..patle d~o he g tI .deetermn whther drugs or other rms of therapy are-

usd*-Ho drucigsare dealt. with. by the body-absorption,distrsibtion, meabolism and excre lon" la h thisrelates ^to e..:* .Indigrle inf-ormatin a'bo t4rd.r -similar.ities....d....... 'betW. eted r e

"Wimsikdfd mpiehf teirprdts ;

IMTdF: te' i-axet aiagerdi reneO*^heus i..bezoi..e.pirre n..the mangeent of:

an.rx-e.ty. an, thir.use for indu g e. t rribing forthre d ,e ypes of aflxioatie. :re..a:nt other"

.*E.xampdes of. the importanfeof th.e...pharm.acokineticdifferences, between related drugs building on. Module.

*A.`.Xppr opriAt -prescri:bing policies, considering bothshoio*a.nd'ngtrm adversemv t o th .H tm.anagewithdrawal from bnziapi e

ModiIe 3antbioticPbleniMsf a icp in h se of antibli'otics.

*Apwlicaion.of pharmaclolin epriniples. and consid-evation .:of;relevant factors such as age, differential organfuntio.n ard.specific.disease.-*Building up an antibiotic pol0icy. Logical decision mak-ing: the range of choices available selectng them withreX.gard t.o -efficacy, safety, conventence ad cost. hang-er.th-epolic.I :v..

243

drug therapy were outlined and discussed by the partici-pants. A report of each meeting was presented to the courseteam and recommendations for the development of thecourse were made.

Secondly, the second draft of each module was sent to agroup including general practitioners, course organizers,recent trainees, clinical tutors and a postgraduate dean.They were asked to work through the draft and its activitiesand to annotate it as fairly and fully as possible with theirthoughts, reactions, comments and criticisms. Reports werediscussed in course team meetings and revisions made in thedrafts.

Finally, the group sessions and draft group leader's noteswere tested in practice with an established, informal con-tinuing education peer group of general practitioners and avocational training group. As it would be in practice, each

tutor planned and used the module and ran the groupmeetings according to his own needs and those of the group.The group meetings were observed by evaluators and notestaken. In addition, the group leader was asked a variety ofspecific questions about the adequacy of the guidance hehad been given. All findings were taken into account inpreparing the final group leader's notes.

Topics in drug therapy has now been available and used forover a year. During this time a field testing programme usingsurvey and observation methods has been underway. Re-sults will be available this year when the possibility ofproducing further modules will be reviewed.

Further information and order forms can be obtainedfrom Ms Monica Howes, Centre for Continuing Education,The Open University, PO Box 188, Sherwood House, Sher-wood Drive, Bletchley, Milton Keynes MK3 6HW. Tel: 0908-71231.

LETTE RS

Discarding Patients'RecordsSir,I wish to make a plea to my fellowgeneral practitioners to be more scru-pulous about a practice which to mymind has a disturbing currency. Whenrecords are being prepared for summa-rization, some letters and some con-tinuation cards are being system-atically destroyed on a ratherwholesale basis, often because theyare bulky or old. No doubt summariza-tion is well intended: problem orienta-tion, prominence of salient infor-mation, storage space liberation, aninstantly accessible yet often not up-dated medical history useful for refer-ral letters and insurance forms, com-puter record preparation and so on.However, once the records are sum-

marized and tagged into chronologicalorder, the temptation is to discardsome of the original letters and pathol-ogy forms. Some of these are repetitiveand have copies elsewhere and someof these details can be entered retro-spectively onto the continuation cards.There may be, then, a good case forcarefully discarding some of them.My concern arises when continu-

ation cards themselves are discarded.The views often stated in defence ofthis practice are that the entries aretrivial, irrelevant, illegible or not sig-nificant, or, indefensibly, not disposedto easy summarization.My views on this practice are that it

is misguided and presumptuous.Doctors do not own patients' re-

cords. They are held on trust, and thepatients expect the doctor to keepthem carefully, in their entirety, even ifthe edges are trimmed here and there.

Also, a doctor has a right to expect thatwhat he writes will be preserved. Ifcontinuation cards are destroyed, thereis no way of knowing how many havebeen destroyed, by whom or for whatreason.

I reserve the right to make my ownsummaries without the earlier evi-dence being destroyed. It is all too easyto rely on other people's summariesuncritically. I have little confidence inthem. Summarization is particularly ar-bitrary and mistakes are inevitable.Omissions are inherent. (How couldone be sure that adenoids were re-moved with the tonsils, or that one orboth. ovaries had been preserved fol-lowing a hysterectomy, without theoriginal details being kept?)When summarizing, no doctor has

the right to predetermine some cate-gories of events, problems, diagnosesor other labels as being worthy of aplace on a summary card, to the ex-clusion of others. Some of these mustbe uncategorizable, and are only defin-able in the way that they have alreadybeen expressed, in full, in the contem-poraneous entries on the continuationcards. Some doctors are accomplishedartists in using these records in a man-ner likened to using a canvas on whichimages of the patient are dabbed on ina variety of colours and strokes when-ever the patient presents. A lot can belearned from the picture as it develops:how the patient is helped or nothelped, attended or did not attend, themood the doctor was in, the diffuse-ness or conciseness of the entry, whatwas said by the patient and so on.

Even the most subtle punctuationcan relay a message. A question markplaced before a diagnosis may repre-sent the doctor sticking his neck out; if

placed after the diagnosis, maybe sec-ond thoughts. Such brushwork defiesclassification and should be preserved,even if open to several interpretations.It is often more accurate in its own waythan a label on a problem list.

Unfortunately, I find when lookingthrough old records that most are un-graphic, often dreary, too often unin-telligible and ever too often illegible.The remedy is not to destroy what waswritten, but to be careful not to perpet-uate these qualities in what we current-ly write.

Indeed we should be ever mindful ofthe next general practitioner inheritingour records: as patients change doctormore often, records are entrusted to uson an increasingly temporary basis. Tohelp the next general practitioner wecould, for example, spruce up ournotes before forwarding them, andmaybe write an appropriate epilogue.

In the meantime, we should make itour business to preserve the recordscarefully without discarding the irre-placeable material in the continuationcards.

MICHAEL JOLLES78 Greenfield GardensLondon NW2 1 HY.

John Stevens MemorialFundSir,In 1983, (April Journal, p.250)1 reportedthe loss of John Stevens at sea andasked for suggestions for ways in whichwe might remember him and his work.The East Anglia Faculty have formed

a Trust Fund to be known as the JohnStevens Memorial Fund. The Fund willbe administered bv four trustees ap-

244 Journal of the Royal College of General Practitioners, April 1984