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E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Tr

Dear Richard;
 
> 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. 
(refs 17-27)

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 
Prescribing. 

(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. 

Best regards;

Dr. Y.E. Kocabasoglu
University of Groningen
Faculty of Medical Sciences
Department of Clinical Pharmacology


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General Introduction. Br J Clin Pharmac, 35:577- 579, 1993. 

04.     SNELL
BF. Rational prescribing: the challenge for medical educators. Med J
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05.     VESTAL RE, BENOWITZ NL. Workshop on
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and Therapeutics in Medical School. J Clin Pharmacol, 32:779-797, 1992

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Gezondheidswetenschappen. VSNU, Utrecht, 1992. 

07.     NIERENBERG DW. A
Core Curriculum for Medical Students in Clinical Pharmacology and
Therapeutics. Clin Pharmac Ther.48:603-605, 1990 

08.     NIERENBERG DW.
Consensus for a Core Curriculum in Clinical Pharmacology for Medical
Students. Clin Pharmac Ther. 48:606-610, 1990 

09.     DE VRIES TPGM.
Teaching Prescribing: A New Approach. WHO Essential Drugs Monitor,
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11.     BRODY J.
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12.     Fischer JN, Gourly,
DRH, Greenbaum, LM [eds]). Association for Medical School
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Practice. Can Med Assoc J. 154(7): 1013-7, 1996. 

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GURWITZ JH. Drug therapy. Lancet. 346(8966): 32-6, 1995. 

19.     NABISWA
A, GODFREY R. Irrational Drug Prescribing in Developing Countries.
Lancet. 343(8893): 358-9, 1994. 

20.     LEXCHIN J. Misuse of Antibiotics
in Hospitals. N Z Med J. 101(852): 548, 1988. 

21.     AVORN J, et al. Use
of Psychoactive Medication and the Quality of Care in Rest Homes. New
Engl J Med, 320:227-237, 1989. 

22.     HARVEY K. What influences
prescribing--scientific articles or promotional pressure? Med J Aust.
149(11-12): 720, 1988. 

23.     WALKER, G. Introducing Concepts of
Essential Drugs / Limited Lists of Drugs. WHO, Geneva, 1987. 

24.      WORLD HEALTH ORGANIZATION. World Drug Situation. WHO, 
Geneva, 1988.

25.     DUKES MNG, HAAIJER-RUSKAMP FM. More Health for Less Money. Lancet,
ii:91-92, 1987. 

26.     VANCE MA, MILLINGTON WR. Principles of Irrational
Drug Therapy. Int J Health Serv. 16(3): 355-62, 1986. 

27.     AZARNOFF DL.
Do we achieve Rational Drug Therapy? (In Handbook of Clinical
Pharmacology. Bochner F [ed]). Little, Brown & Co., Boston, 1983.

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