teaching safe and effective prescribing in uk medical schools: a core curriculum for tomorrow's...

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© 2003 Blackwell Publishing Ltd

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Blackwell Science, Ltd

Oxford, UK

BCPBritish Journal of Clinical Pharmacology

0306-5251Blackwell Publishing 2003

55

6496503

Original Article

Teaching safe and effective prescribing in UK medical schoolsS. Maxwell & T. Walley

Correspondence:

Dr S. R. J. Maxwell, Clinical Pharmacology Unit, University ofEdinburgh, Western General Hospital, Edinburgh EH4 2XU, UK. E-mail:[email protected]

Received 12 March 2003, accepted 12 March 2003.

Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow’s doctors

Simon Maxwell & Tom Walley

1

Vice-President (Clinical), British Pharmacological Society, and Clinical Pharmacology Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, and

1

Chairman, Clinical Section Committee, British Pharmacological Society, and Department of Pharmacology andTherapeutics, University of Liverpool, Liverpool L69 3GF, UK on behalf of the BPS Clinical Section Committee

There is a pressing need for medical graduates to be fully prepared to take on theresponsibilities of prescribing and to be able to respond to continual inevitable rapidchanges in therapeutics. The curricula in UK medical schools were greatly influ-enced by

Tomorrow’s Doctors,

published by the General Medical Council in 1993.This has recently been updated. While it highlights the management of disease anduse of drugs as key learning objectives, it offers little specific guidance. In thisdocument we expand on these broad statements, provide a view of how theselearning objectives might be achieved, and identify the key elements of a corecurriculum in prescribing and therapeutics.

Keywords:

clinical pharmacology and therapeutics, curriculum, education, GeneralMedical Council, prescribing, undergraduate

Introduction

Prescribing is a major clinical activity of the NationalHealth Service (NHS). Each member of the populationnow receives an average of 12 prescriptions per year. Thecost of prescribing has grown progressively throughoutits existence and now amounts to a total annual expen-diture in excess of £7bn, about 13% of the total budget.For most doctors, drug therapy is the main tool that theyhave for influencing the health of their patients. Whiledrugs can offer great benefits to patients, they can alsocause great harm.

There are several important pressures on all NHSprescribers:

• New drug developments, extending medicines intonew areas.

• Increasing complexity of medical care.• Increased specialization.• Increased use of medicines in both primary and sec-

ondary care.• More rapid throughput of patients.• Sicker and older patients, more vulnerable to adverse

effects.

All of these strengthen the need for newly qualifieddoctors to have a firm grounding in the principles ofsafe, effective, and cost-effective prescribing.

Prescribing as a generic skill

Prescribing is the primary intervention that most doctorsoffer to influence their patients’ health – whatever careermedical graduates decide to pursue, most will have toremain ‘specialists’ in drug prescribing. Prescribing istherefore an essential skill for doctors in most medicalspecialties. Most graduates will require not only a knowl-edge of today’s drugs, but also a firm grounding in theprinciples of therapeutics, underpinned by a scientificknowledge of drug action, to inform their learning aboutfuture developments.

In addition, prescribing rights are now being extendedto other health professionals, and doctors will increasinglyneed to be involved in training and in working collabo-ratively with these other prescribers.

With the power to bring great benefits comes therisk of causing great harm, as drugs can cause signifi-cant morbidity and mortality. Although newly qualifieddoctors are usually protected from the requirement toundertake high-risk practical procedures, they are oftenexpected to prescribe powerful drugs from their firstday of clinical work. This is a high-risk area of practice,and a major clinical governance issue for employers,

Teaching safe and effective prescribing in UK medical schools


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who look to medical schools to ensure that their grad-uates have the necessary skills and knowledge for suchwork.

For all of these reasons, a firm grounding in the prin-ciples of prescribing and therapeutics, an understandingof how drugs work, and a basic knowledge about com-monly used drugs are essential for all medical graduates.But a concern of a recent Audit Commission report [1]was that current undergraduate medical courses ‘do notprovide a thorough knowledge of safe medicines pre-scribing and administration’ among junior doctors. Thereis a pressing need to improve the training of prescribersat all levels. Medical education in the UK has undergonesignificant changes over the last decade, in response toconcerns over traditional methods of teaching and drivenby recommendations from the General Medical Council(GMC). Now is an appropriate time to consider whetherUK graduates are adequately prepared to prescribe.

Medical school curricula

Traditionally, UK medical schools ran a 2- or 3-yearpreclinical phase of ‘basic sciences’ as a foundation for3 years of clinical training. In the 1960s, clinical phar-macology and therapeutics (CPT) emerged as a newdiscipline, and many schools incorporated CPT intocurricula as a distinct course. Many medical schools pro-vided courses in both basic pharmacology and CPT.However, there were problems with these generalarrangements: an excessively high burden of factualinformation, an emphasis on basic science, which oftenexcluded time for other patient-centred activities, poorco-ordination across courses, and an artificial dividebetween preclinical and clinical learning. There werealso weaknesses in the learning process, with an excessof didactic lecture-based teaching rather than activeproblem-based learning.

The GMC document

Tomorrow’s Doctors

in 1993 rec-ommended changes to the structure and content of med-ical education [2], that the factual burden be reduced,and that integration be improved. The emphasis was onproblem-based education and the development of skillsfor lifelong learning. Learning outcomes in the form ofknowledge, skills, and attitudes were to be clarified.

Reasons for concern

For many schools, this prompted a radical redesign of themedical curriculum, one consequence of which was theloss of single-discipline courses, including basic pharma-cology and CPT. Indeed, the guidance stated explicitlythat it ‘avoided all reference to traditional subjects anddisciplines… urging the advantages of interdisciplinarity’

(Para. 42). Although


did identify ‘theprinciples of therapy’, including ‘the actions of drugs,their prescription and their administration’ among itsknowledge objectives [Para. 40.1(g)(ii)], there was noother mention of drugs or prescribing.

Now learning about CPT has devolved to system-or problem-based components of the curriculum.Although there are no objective data on how this hasaffected learning outcomes, in practice it is now harderto bring together the core principles of CPT thatunderpin good prescribing. These concerns have beenraised by many, including medical students themselves[3, 4]. The diminished presence of CPT is ironic inthat it remains one of the most ‘integrated’ of all clini-cal disciplines, its core principles applicable to almost allother areas of practice.

The GMC’s own recommendations for early postgrad-uate medical education,

The New Doctor

[5], clearly iden-tify the need for a sound education in therapeutics:‘Practical skills frequently required by preregistrationhouse officers . . . from the first day of the preregistrationyear . . . [and that] should not be undertaken withoutproper training . . . [include the ability to] calculate adrug dosage’, and ‘write a prescription’.


2002

The GMC has recently revised


[6], andits implications have been discussed at length elsewhere[7]. The new guidance provides more direction aboutteaching and assessment of therapeutics than before andspecifically refers to effective and safe use of medicinesas the basis of prescribing (item 16). The key guidanceis that students must be adequately prepared to prescribedrugs when they graduate (item 52). It also addressesevaluation of effectiveness against evidence, the need totake account of patients’ views and beliefs, and the useof complementary and alternative therapies (item 18).Graduates must be able to go beyond a managementplan, to work out drug dosages, and write safe prescrip-tions for different types of drugs (item 19). Importantly,they are expected to know how errors can happen inpractice and to apply these principles to risk management(items 4 and 26). The need for a firm grounding in theprinciples of CPT and knowledge about common drugsis strengthened by the expectation that graduates will beable to provide enough information about conditions andpossible treatments to help patients make informed deci-sions about their care (item 30).

These learning outcomes are now supported by clearrecommendations on effective assessment. Medicalschools must have valid and reliable schemes of assess-ment, to ensure that students have achieved the curricularoutcomes (items 62–64).

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An integrated core curriculum in clinical pharmacology and therapeutics

The 2002 revision of


does not supportthe re-emergence of CPT as a specific discipline, but theincreasing emphasis on many learning outcomes at theheart of CPT is welcome, as well as the clear principlethat all graduates must be demonstrably safe prescribers.While the specific details of this objective are not speltout, we believe that it must involve most of the genericknowledge, skills, and attitudes suggested later in thispaper, as well as specific knowledge about the drugsprescribed. The real challenge now for all medical schoolsis to deliver and assess these learning objectives withinan integrated curriculum.

Previous recommendations about the content of CPTwithin the curriculum, in both the UK [8] and USA [9],remain valid and should be re-emphasized. There isnow a need to re-interpret them in the context ofthe new curricula and in line with the latest GMCrecommendations.

The purpose of the remainder of this document is:

• to translate the general objectives related to CPT intomore specific learning outcomes;

• to prioritize the core learning objectives in CPT;• to identify the minimum knowledge that students

should possess to prescribe safely and effectively at thetime of graduation;

• to indicate how these objectives can be achieved in anintegrated medical curriculum;

• to provide a template for quality assurance for thosewho review the undergraduate medical curriculum inUK medical schools;

• to support the development of assessments of learningoutcomes;

• to highlight the importance of strong leadership intherapeutics in all medical schools, as the best way toensure successful integration of the core content intothe curriculum and the development of effectiveassessments;

• to provide direction for curriculum developers, partic-ularly where CPT specialists are absent.

Core learning objectives

The key objective is that graduates be competent toprescribe safely and effectively. In addition, they shouldbe able to assimilate information about new drug devel-opments throughout their professional career. These gen-eral objectives can be further refined into more specificoutcomes, which can be divided into knowledge andunderstanding, skills, and attitudes, and form the corecontent of CPT within the curriculum (Appendix).

Although this content is identified here as ‘CPT’, thatspecific label is not a prerequisite for the success of thelearning outcomes. To keep these objectives clinicallyrelevant, it is useful to link them to a number of specificdrugs (perhaps the basis of a ‘student formulary’, seebelow) and therapeutic problems that provide relevantclinical examples of the principles of CPT. Each schoolwill wish to develop its own lists and format, but anexample of a core drug/therapeutic problem list can befound in a longer version of this paper [10]. Both listshave been set out in relation to the potential clinicalmodules in which those learning objectives are mostlikely to be met. This emphasizes the suitability of aproblem-based approach to develop learning about CPT,and how CPT can be vertically integrated with most ofthe curriculum.

A ‘curriculum map’ should be given to the students,who will then be able to identify how the relevantlearning objectives can be achieved. A sound knowledgeof the basic principles of CPT should allow students totake a logical approach to learning about any of the drugsthey encounter during the course, and should thereforebe introduced at an early stage of the curriculum.

Core drugs and therapeutic problems: the Student Formulary

Medical students are often overwhelmed by the largenumber of drugs that they encounter during their clinicalattachments. To tackle this, schools should create a list ofdrugs as the basis for a ‘student formulary’ that helps toprioritize learning. The list should comprise 80–100commonly used drugs from both primary and secondarycare settings, that are used to treat common illnesses andare representative of important drug classes. A newlyqualified doctor might be expected to initiate or pre-scribe these drugs under the direction of a senior doctor.For each of the drugs or its class, students might beexpected to:

• know its name and class;• understand how it works;• recognize the appropriate indication for its use;• know how to prescribe it – how it is administered,

the frequency of administration, the duration ofadministration;

• know its important contraindications, potential druginteractions, and major adverse effects;

• be able to name alternatives when available;• know how to monitor the drug’s effects;• be able to explain salient features of all of these points

to a patient.

Students need not be expected to know exact drugdoses, except perhaps for a small number of emergencydrugs, but should know where to find the information



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quickly and easily. The newly qualified prescriber shouldbe expected and encouraged to look up doses beforeprescribing any drug.

The intention of the student formulary is to providerealistic and attainable learning objectives. A student whoachieves these outcomes should be able to cope effec-tively and safely with most of the prescribing challengesthat they are likely to face in their early postgraduateyears, as well as establishing the key principles of goodprescribing for the rest of their careers.

Delivering the curriculum

The structures of medical courses in the UK differ con-siderably. While some retain boundaries between preclin-ical and clinical, others have removed these barriers andhave truly integrated curricula, often with an emphasison problem-based learning. All of the CPT learningobjectives can be achieved in either setting. This may beeasier in discipline-based courses. In more integratedcourses, the absence of protected time to focus on pre-scribing necessitates the co-ordination of CPT learningopportunities across many different modules and overseveral years. This task may present practical difficulties.

Whether in a traditional or an integrated curriculum(Figure 1), learning about drugs should be built upthroughout the course – initially emphasizing under-standing where and how drugs act, using core drugs asexamples, and later emphasizing clinical aspects, such aswhen drugs are indicated and how they are prescribed.Curriculum developers might see an advantage in a mod-ule in the early years that highlights generic aspects ofdrug use. With these key principles established, muchof the learning about drugs can be undertaken withinsystem-based modules to provide both horizontal andvertical integration.

Leadership

A key factor in the successful implementation of the corecurriculum will be clear leadership.


2002 emphasizes the need to ‘involve individuals with anappropriate range of expertise and knowledge’ to ‘plancurricula and associated assessments, put them into prac-tice and review them’ (item 42 [6]). All medical schoolsshould be able to identify an individual to oversee thisarea of the curriculum. This role might ideally be under-taken by an individual with training and background inCPT. But the role is not their sole preserve and the keyrequirements are enthusiasm for ensuring that principlesof CPT are prominent throughout the curriculum.

CPT learning opportunities may be devolved to manyteachers across the course, often within organ-based spe-cialties. They too should be encouraged to emphasize

these principles and remind students about the effects ofdrugs beyond individual organ systems. Simply providinga link between drugs and clinical conditions is insuffi-cient to develop an appreciation of the complex consid-erations that surround the decision to prescribe.

Teaching and learning styles

The range of modes of learning will vary in differentschools according to local preference, but the key isincreasingly inquisitive rather than passive learning. Thereshould be an appropriate balance of teaching in largegroups with that in small groups, practical classes andopportunities for self-directed learning. Although the

Figure 1

Traditional and integrated patterns of delivery of clinical pharmacology and therapeutics in the undergraduate medical curriculum. (a) Traditional curriculum. (b) Integrated curriculum.

Preclinical

Clinical

YEAR 1

YEAR 2

YEAR 3

YEAR 4

YEAR 5

Clinical specialty attachments

Pharmacology Exam

Clinical specialty attachments

Basic Pharmacology (how and where drugs work)

Physiology, Anatomy, Biochemistry Pharmacology Exam

Therapeutics Exam

FINALS

SurgeryMedicine

Therapeutics Course

Clinical Pharmacology Course

Pharmacology Course

Pharmacology Course

(a) Traditional Curriculum

(b) Integrated Curriculum

CURRICULUM VERTICAL THEMES

including

Clinical Pharmacology & Therapeutics

YEAR 1

YEAR 2

YEAR 3

YEAR 4

YEAR 5

Therapeutics in clinical specialty modules

Integrated Assessment





Therapeutics in clinical specialty modules

Principles of Clinical Pharmacology

Basic Pharmacology (how drugs influence diseases)

Basic Pharmacology (how and where drugs work)


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didactic lecture still has a role in delivering a broadoverview of individual topics, it is now only one ofseveral approaches.

The core curriculum in CPT is ideally suited to takeadvantage of problem-based learning. Most prescribingepisodes try to solve a clinical problem and require theappropriate knowledge, skills and attitudes outlined inthe Appendix. Several schools have developed ‘therapeu-tic case discussions’ that offer students a case vignette andpose problems relating to prescribing and therapeutics.There are also several initiatives to develop case-basedcomputer-assisted learning packages as aids to CPTlearning and self-assessment.

Many opportunities for students to learn about drugswill arise during clinical attachments. Students shouldobserve the process of prescribing from the perspectiveof other healthcare professionals (e.g. participate in award ‘drug round’). They might be asked to review drugsheets, make self-assessments about their knowledgeabout specific core drugs, look for potential drug inter-actions, and scrutinize prescriptions. Students shouldreceive instruction in small groups about the practicalaspects of writing a legal prescription.

Other styles of learning might involve writing casereports containing discussion about therapeutic aspects(e.g. portfolio cases), discussing prescribing decisionswith patients as part of communicating skills, criticallyanalysing clinical trials involving drugs, appraising claimsabout new drugs, and searching for information aboutdrugs.

Assessment of the core curriculum

Assessment drives learning and consolidates the acquisi-tion of core knowledge and skills. The recent GMCrecommendations are clear. Safe and effective use ofmedicines is also a major factor in clinical governanceand risk management within the NHS. For these rea-sons, a robust assessment of prescribing competenceshould be mandatory. Its presence should be verified byexternal examiners and when the GMC visits medicalschools.

Students might also be provided with formative assess-ments and the chance for self-assessment at regular inter-vals during the medical course. Few schools now have aseparate ‘CPT examination’. In an integrated curriculum,the learning process in CPT spans the course andinvolves the synthesis of numerous learning opportuni-ties. It is therefore logical to reserve important summativeassessments for later in the course, preferably the finalyear, when students can be expected to demonstrateexpertise in many different areas of therapeutics (similarto real clinical life). The assessment should identify stu-dents who have poor knowledge about drugs and who

will be inadequately prepared for the responsibility ofprescribing.

Even within an integrated assessment scheme, thereshould be a clear, identifiable, and robust componentdevoted to the knowledge and skills that support theprescribing of drugs. Furthermore, it is inappropriate thatany student should be able to compensate for a poorperformance in prescribing or therapeutics with goodperformances in other assessments. The GMC guidanceis unequivocal on the need for students to be competentprescribers when they graduate (item 52).

The mode of assessments may vary, but they shouldtest the knowledge, skills, and attitudes that are identifiedin the core curriculum, in a manner that is relevant toearly clinical practice. Although knowledge and under-standing can be examined by essays and multiple-choicequestions, assessments should increasingly focus on test-ing the acquisition of practical skills. These may be moreadequately assessed in the format of an objective struc-tured clinical examination (OSCE) [11].

Conclusion

Although guidance from the GMC has led to substantialimprovements in the quality of education, it has posedchallenges in ensuring that many learning outcomes, pre-viously the responsibility of individual disciplines, are metwithin an integrated curriculum. Meeting this challengein CPT assumes greater importance as the complexitiesof being a prescriber grow. The medical curriculumshould offer all students a firm grounding in core knowl-edge and understanding about drugs, skills in prescribing,and attitudes towards the use of drugs. These principlesshould be applied to a limited and identifiable list ofcommon drugs. Although specialists in CPT have animportant role to play in leading this area of the curric-ulum, teachers from other backgrounds can also fulfil thisrole.

This document is intended as a support to thosecharged with overseeing the development of this area ofthe curriculum. The GMC indicates that ‘medical schoolshave a responsibility to the public, to employers and tothe profession to make sure that graduates are fit topractice’ (item 84 [7]). Prescribing drugs is a key com-ponent of medical practice. All of tomorrow’s doctorsmust be adequately prepared.

Principal recommendations

• Prescribing and therapeutics should be identified as animportant theme that runs vertically through the med-ical curriculum, integrating with and identifiablewithin relevant horizontal modules.



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• Core learning objectives should be clearly identified,including knowledge and understanding about drugs,skills related to the prescribing of drugs, and attitudestowards drug therapy.

• The factual burden should be eased by prioritizinglearning around a core list of commonly used drugs (astudent formulary).

• There should be identifiable and robust assessment thatthese learning objectives have been met. This mightform part of an integrated assessment, but it should notbe possible to compensate for a poor performance inthis area by a good performance in other items.

• Each medical school should identify an individualteacher to oversee this area of the curriculum and toensure that the learning objectives set out within thecore curriculum are met.

The authors would like to acknowledge the contribution of themany individuals who offered constructive comments about earlierversions of this manuscript. A longer version of this article isavailable on the BPS web site at http://www.bps.ac.uk [10].

Appendix: Core knowledge and understanding, skills and attitudes concerning the use of drugs for the medical curriculum

These should be key learning outcomes of the curricu-lum and are required by all graduates, to enable them toprescribe safely and effectively at the point of qualifica-tion. These core objectives are generic and applicable tomost areas of therapeutics. They should be considered inassociation with a locally identified list of core drugs andtherapeutic problems to which they apply. In each casetheir relevance to clinical practice should be illustratedwith appropriate examples.

Core knowledge and understanding

Basic pharmacology

The general mechanisms of action of drugs at molecular,cellular, tissue, and organ level;the ways in which these actions produce therapeutic andadverse effects;the receptor as a target of drug action and related con-cepts such as agonism, antagonism, partial agonism, andselectivity;the development of tolerance to drugs.

Clinical pharmacokinetics

The mechanisms of drug absorption, distribution, elim-ination (metabolism and excretion);the concepts of volume of distribution, clearance, andhalf-life, and their clinical relevance;how these factors determine the optimal route, dose, andfrequency of drug administration.

Factors that determine interindividual variation in drug response

Pharmaceutical variation;pharmacokinetic handling of drugs;pharmacogenetic variation.

Monitoring drug therapy

The importance of monitoring the impact of drug therapy;the ways in which this can be achieved (measuring clin-ical outcomes, pharmacodynamic responses, or plasmadrug concentrations);the variable relation between plasma drug concentrationand drug effect.

Adverse drug reactions

Types and mechanisms of adverse drug reactions;the frequency of adverse reactions in primary and sec-ondary care;recognition of the predisposing factors and how risks canbe minimized;the importance of reporting adverse reactions and therole of the yellow card scheme.

Drug interactions

The potential for drugs to interact to cause beneficial andharmful effects;the mechanisms by which drugs interact (pharmacoki-netic, pharmacodynamic);the ways in which interactions can be predicted and avoided.

Medication errors

The common reasons medication errors occur in practice;the ways in which individual prescribers can reduce therisks of medication errors.

Poisoned patients

Principles of treating the poisoned patient;the assessment of poisoned patients;the recognition and treatment of common presentations(e.g. paracetamol);the principles of removing or counteracting the effectsof toxic substances after ingestion.

Prescribing for patients with special requirements because of their altered physiology, pharmacokinetic handling, or pharmacodynamic responses, including

Elderly patients;children;women of child-bearing potential;pregnant and breast-feeding women;patients with renal disease;patients with liver disease.

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Legal aspects of prescribing drugs

Categorization of drugs as over-the-counter formulations(General Sales List and Pharmacy medicines),prescription-only medicines, and controlled drugs;the prescribing of ‘unlicensed’ medicines or medicines‘off label’;the responsibilities associated with prescribing controlleddrugs.

Developing new drugs

Drug development, including clinical trials (Phase I toPhase IV);the approval process and major regulatory authorities inUK and Europe;the requirements of good clinical trial design;consent, ethics, bias, statistics, dissemination ofinformation.

Medicines management

The role of local formularies;the roles of drug and therapeutics committees;the influences that affect individual prescribing choices;the rational assessment of new drugs, based on safety,efficacy and cost-effectiveness.

Ethics of prescribing

Informed patient consent and concordance.

Commonly used drugs

The mechanism of action, the indications for use, theappropriate route of administration, and the importantcontraindications and adverse effects of a locally identi-fied list of commonly used drugs (see for an examplehttp://www.bps.ac.uk [10]).

Common therapeutic problems

The management of common acute and chronic thera-peutic problems (see for an example http://www.bps.ac.uk[10]).

Complementary and alternative medicine

The motivations that lead patients to seek complemen-tary and alternative therapies;some common methods and appraisal of the evidence fortheir efficacy;how such therapies can interact with prescription drugsthat patients are receiving.

Core skills

Taking a drug history

Obtaining accurate information about current prescrip-tion and non-prescription drugs;making an assessment of adherence to a medication regimen;

recording current and past adverse drug reactions, includ-ing allergies.

Prescription writing

Choosing a safe and effective drug and an appropriatedosage regimen;writing accurate, legible, and legal prescriptions, includ-ing controlled drugs;keeping accurate records of prescriptions and responses;calculating drug doses;calculating the strength of an infusion based on therequired rate of drug administration;prescribing oxygen (flow rate, delivery);prescribing intravenous fluids.

Drug administration

Selecting the appropriate route of administration;giving subcutaneous, intramuscular, and intravenousinjections;preparing drugs for parenteral administration, includingmixing and dissolving drugs;preparing and giving drugs by an infusion pump;preparing and giving nebulized drugs;advising patients about special modes of drug delivery,e.g. topical, inhaled, insulin.

Prescribing drugs in special groups

Elderly, children, pregnancy, breast-feeding, renal andhepatic failure.

Prescribing drugs to relieve pain and distress

Palliation of pain and other distressing symptoms.

Adverse drug reactions and interactions

Assessing drugs as possible causes of symptoms andsigns;recognizing the potential for adverse drug interactions;reporting adverse drug reactions and interactions.

Drug allergy

Recognizing allergic drug reactions and taking a historyof an allergic reaction;treating allergic reactions, the emergency treatment ofacute anaphylaxis.

Clinical pharmacokinetics

Using core knowledge of pharmacokinetics to informsafe prescribing.

Monitoring drug therapy

Identifying which therapeutic effect to observe;using measurements of plasma drug concentrationsappropriately (which and when);acting appropriately on the results.





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Analysing new evidence

Practising evidence-based prescribing;assessing the validity of evidence about new drugs ortherapies;reading, assessing, and critically analysing clinical studies;spotting methodological flaws, including sources of bias;recognizing the difference between true and surrogateend-points.

Obtaining accurate objective information to support safe and effective prescribing

Using the British National Formulary;accessing reliable drug information from medical journalsand medical databases;accessing Poisons Information Services;discriminating between the reliability of varying sourcesof evidence and opinion.

Obtaining informed consent to treatment

Providing patients with enough information about drugsto allow them to make informed decisions about theirtreatment;discussing benefits and risks of drug therapy with patients;exploring patients’ own views and wishes in relation todrug treatment.

Core attitudes

A rational approach to prescribing and therapeutics

Identify-ing the correct diagnosis;understanding the pathophysiological processes involved;knowing the drugs that might beneficially influence theseprocesses;establishing the end-points with which to monitor thetherapeutic response;assessing the potential risks and benefits of treatment;communicating with the patient in making the decisionto treat.

Risk–benefit analysis

Recognizing that there are risks and benefits associatedwith all drug treatments;recognizing that these may differ between patients,depending on a variety of factors;recognizing that doctors should monitor the impact ofthe drugs they prescribe.

Recognizing the responsibilities of a doctor as part of the prescribing community

Avoidance of wasteful prescribing and consumption oflimited resources;

recognizing the need to report adverse drug reactions forthe common good;controlling the availability of restricted drugs;adhering to therapeutic guidelines and drug formularies,as appropriate;avoiding indiscriminate antibiotic prescribing.

Recognizing personal limitations in knowledge

Recognizing the need to seek further informationabout drugs when faced with unfamiliar prescribingproblems.

Responding to the future

Recognizing the need to update prescribing practices;ensuring that patients benefit, when possible, fromadvances in medical knowledge;recognizing the need to assess the benefits and hazards ofnew therapies;knowing the limitations of applying clinical trial data toindividual patients.

References

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A spoonful of sugar – improving medicines management in hospitals

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3 Maxwell S, Walley T, Ferner RE. Using drugs safely: undergraduates must be proficient in basic prescribing.

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8 Walley T, Webb DJ. Core content for a course in clinical pharmacology. Br J Clin Pharmacol 1997; 44: 171–174.

9 Nierenberg DW, and the Council for Medical Student Education In Clinical Pharmacology and Therapeutics. A core curriculum for medical students in clinical pharmacology and therapeutics. Clin Pharmacol Ther 1990; 48: 606–610.

10 Maxwell S, Walley T. Teaching safe and effective prescribing in uk medical schools: a core curriculum for tomorrow’s doctors (long version). http://www.bps.ac.uk/

11 Langford NJ, Martin U, Kendall MJ, Ferner RE. Medical errors. Medical schools can teach safe drug prescribing and administration. Br Med J 2001; 322: 1424.

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