> Despite the excellent work done in evaluating the WHO/Groningen
> Guide to Good Prescribing I remain very sceptical that training in
> undergraduate academic settings has any benefit though I would like to be
> proved wrong. I believe that young medical students or student nurses learn
> and know a great deal of relevant therapeutics.
I do not agree with your above comments completely. First, there is
strong evidence that medical students are not always trained adequately in
pharmacotherapy. (refs 1-16). Therefore, it is questionable if they really
learn "a great deal of relevant therapeutics".
Usually pharmacotherapy education, if and
when available, is almost always focuses on teaching basic
pharmacological principles, major drug groups and toxicology in a
rather theoretical fashion, without any emphasis on their clinical
relevance. The emphasis is mostly on the knowledge, with small or no
emphasis is put on the skills of choosing pharmacotherapy
rationally, based on criteria such as efficacy, safety, suitability
and cost. These skills seem to be one of the key factors defining how
applicable the theoretical knowledge fed to the students will be.
A study by Theo de Vries et al (de Vries TPGM, et al. Impact of a
Short Course in Pharmacotherapy for Undergraduate Medical Students:
An International Randomised Controlled Study. Lancet. 346:1454-1457, 1995)
indicated that when appropriate therapeutic skills are taught, the students
manage to choose drugs more rationally for not for the indications
they were taught (retention effect) but also for the indications they
have not been taught (transfer effect).
The same way, the undergraduate exams are usually targeted at
reproduction of the theoretical knowledge, rather than application in
clinical scenarios or reinforcing skills. As J.J. Guilbert says "The
person who sets the examination controls the programme." However
unfortunate it might be, most of the students are exam-oriented
learners as shown in numerous studies, and thefore the nature of the
exams play a significant role in what is learnt. "Changing the
examination system without changing the curriculum had a much
more profound impact upon nature of learning than changing
the curriculum without altering the examination system." as G.E.
Miller once noted.
> . . . However, when they qualify
> and become interns/residents or are posted out of their training
> hospital to a health center they have to learn how to prescribe
> quickly. To do this they identify a safe prescriber, a role model
> and copy that person's prescribing practices.
I agree that students usually "identify a safe prescriber, a role model
and copy that person's prescribing practices." The problem is, how
safe are these role-models. There are quite a lot studies indicating
that less than optimal prescribing still occurs at vthe teaching
hospitals, both in industrialized and industrializing countries.
Unfortunately, irrational drug use behavior is difficult to correct,
as Ken's (Harvey) good study among Australian Doctors have indicated
(HARVEY K, et al. Educational Antibiotic Advertising Campaign. Med
J Aust. 2(11): 536-7, 1983.). Even if for a period of time, the
prescription patterns seem to improve, the irrational behaviour has
shown to rebound. That should not surprise anyone, as a learnt
behaviour, e.g. irrational prescribing, is known to be hard to
correct. Despite many countries introducing essential drug lists,
national therapuetic guidelines, restricted drug lists, irrational
prescription persists. Interestingly studies show that prescribers'
compliance reduces when (1) little is known about the mechanisms
involved in developing these modalities; (2) the drug-selection criteria is not
always transparent to the medical professionals (3) they do not
necessarily actively involve the medical professionals in the drug
selection process, nor are necessarily based on a broad consensus, (4)
the recommendations in these modalities vary significantly.
So the whole idea we are working on is to introduce preventive
measures, before the disease (irrational prescription) roots.
In this context, we in Groningen, are trying to teach
(1) rational drug selection and prescription skills, through
Groningen Method as underlined in WHO Guide to Good
(2) encourage students through 6 years of education to
(a) develop their own personal formularies and use them (so we can
assist in drug selection, they end up with a compiled list of first
line drugs and associated treatment plans self-selected according to
the criteria which is transparent to them).
(3) how to look drug information critically (every student
is required to compile a review article during their undergraduate
studies on therapeutics). Unfortunately, there are no study outcomes
yet, but we hope this exercise will help them to look at drug
information more critically.
> So how could you prove me wrong in my assertion? While your idea of using
> pooled data is attractive I suspect it would be difficult to do and might
> not cleary distinguish. I would suggest that when young prescribers who have
> had rational prescribing training are first placed in a prescribing choice
> situation they should be compared with colleagues who have not received the
> training in how closely they follow agreed Standard Treatment Guidelines.
> You could choose a few conditions with clear agreement on optimum therapy
> where guidelines are often neglected such as surgical antibiotic
> prophylaxis, treatment of diarrhea or ARI or other such conditions. It would
> be difficult to do but would be worth doing.
I would recommend a slightly different setting: Perhaps one should
identify study groups as follows: (1) Trained group I [undergraduate
training in clinical setting], (2) Trained Group II [post-graduate
training in clinical setting / in-service, WITHOUT undergraduate
training] and (2) untrained group. The assessments could be pre-training,
immediate post-training and long-term post-training. It might be interesting to
look at the long-term impact of training, since that will indicate
any behavioural change.
> I would not want to stop the undergraduate rational prescribing training
> though I am sceptical, as it may have a benefit and may sensitize students
> for later training. My priority would be to focus on the residency
> internship experience to ensure that rational prescribing is promoted there.
> I would advocate identifying the opinion leaders, the role models (who may
> not be the consultants) and study their prescribing.
Interestingly, therapeutics education is almost always confined to the
pre-clinical years of undergraduate education. In clinical years, many
students fail to incorporate their assumed pharmacological knowledge
into clinical practice. In Groningen, we started to incorporate
therapeutics to clinical years of education, our pre-tests, although
yet needs to have further data to end up in a definite conclusions,
indicate that therapeutics education in clinical years, using real
patients, outpatient clinics training and self-monitoring has a very
positive impact on the rational drug selection and prescription.I
agree that clinical teachers / role models should be consistent in
their drug selection process with the drug selection model adopted by
the curriculum. That means (1) the model should be adopted by their
contribution and consent, (2) they should be trained particularly to
train their students in therapeutics and make sure that students
understand the logic behind their therapeutic choices.
Dr. Y.E. Kocabasoglu
University of Groningen
Faculty of Medical Sciences
Department of Clinical Pharmacology
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