Can junior doctors prescribe? | Archives of Disease in Childhood

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Can junior doctors prescribe?

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System Failure
Felix Oberender
Published on: 17 July 2008
results grossly misleading
Peter wasswa
Published on: 2 July 2008
If junior doctors can't prescribe, who can?
veena bisht
Published on: 1 July 2008
Not off the top of the head
Anthony R Hart
Published on: 25 June 2008
Off the top of their heads?
Dylan M Wilson
Published on: 24 June 2008

Published on: 17 July 2008
System Failure
- Felix Oberender, Senior Registrar in Paediatric Intensive Care
Thank you for sharing this interesting study. Do such staggering results in this core area of physician activity, however, not also beg the question of system failure? A number of reasons come to mind, eg. time pressures, the frequent need to re-chart, wide variations in chart design etc.
It may seem enticing to include navigating this system in the ST interviews but would it then not just add yet another bell-c...
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Thank you for sharing this interesting study. Do such staggering results in this core area of physician activity, however, not also beg the question of system failure? A number of reasons come to mind, eg. time pressures, the frequent need to re-chart, wide variations in chart design etc.
It may seem enticing to include navigating this system in the ST interviews but would it then not just add yet another bell-curve test to an already generic selection process? Looking for excellence and critical thought, how about presenting your findings to the candidates and asking for their suggestions on how to solve the problem?
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Conflict of Interest:
None declared.
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Published on: 2 July 2008
results grossly misleading
- Peter wasswa, ST1 paediatrics
Dear Sir, The results of the Sheffield paediatric ST interviews are misleading and unlikely to reflect the prescribing skills of junior doctors. I have outlined my reasons below
1. At the interview, the prescriptions are done in a highly pressurised environment with a lot at stake ie careers/dreams. Its a known that highly capable candidates are likely to perform sub optimally when anxious and stressed. It can b...
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Dear Sir, The results of the Sheffield paediatric ST interviews are misleading and unlikely to reflect the prescribing skills of junior doctors. I have outlined my reasons below
1. At the interview, the prescriptions are done in a highly pressurised environment with a lot at stake ie careers/dreams. Its a known that highly capable candidates are likely to perform sub optimally when anxious and stressed. It can be argued that many of the candidates were not in the right state of mind to prescribe at that moment.
2. There was a limited time frame during which the prescriptions had to be completed. During my own interview in Sheffield, there was no clock in the room for candidates to pace themselves as they prescribed. In trying to be extra careful, some candidates were time short. In day to day practice, there are no bells or invigilators standing over doctors as they prescribe.
An audit of the quality of prescriptions done at the work place is probably a more reliable assessment of prescribing skills.
competing interests: attended ST1 paeds interview in Sheffield April 2007
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Conflict of Interest:
None declared.
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Published on: 1 July 2008
If junior doctors can't prescribe, who can?
- veena bisht, SpR paediatrics
Perhaps prescribing should be mandatory part of MRCPCH Part I examination or part of selection process of ST trainees!
It seems to be one of the oft repeated themes and a favourite audit topic for SHOs every 6 months.The prescribing practice has improved significantly over past few years in our trust since it is part of mandatory training during SHOs induction and also the awareness that somebody or the other m...
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Perhaps prescribing should be mandatory part of MRCPCH Part I examination or part of selection process of ST trainees!
It seems to be one of the oft repeated themes and a favourite audit topic for SHOs every 6 months.The prescribing practice has improved significantly over past few years in our trust since it is part of mandatory training during SHOs induction and also the awareness that somebody or the other must be auditing the prescribing practice.The nursing staff is also more aware and alert towards prescribing errors.
By the way has somebody done a study on prescribing practice by pharmacist in the acute ward or emergency situations!That may be gold standard. Or for that matter prescribing practice of consultants?
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Conflict of Interest:
None declared.
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Published on: 25 June 2008
Not off the top of the head
- Anthony R Hart, Clinical Research Fellow
I thank Dr Wilson for his e-letter about our letter on prescribing skills in junior doctors. I have outlined answers to his questions below.
All candidates had access to a BNF and calculator. Whether a drug dose, such as salbutamol, was written on the PRN side or the regular side of the drug chart did not influence marking, so those with no previous experience of the chart or our usual prescribing habits wer...
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I thank Dr Wilson for his e-letter about our letter on prescribing skills in junior doctors. I have outlined answers to his questions below.
All candidates had access to a BNF and calculator. Whether a drug dose, such as salbutamol, was written on the PRN side or the regular side of the drug chart did not influence marking, so those with no previous experience of the chart or our usual prescribing habits were not penalised.
Doses were unreasonable if they included several decimals or where amount could not be administered up easily. For example, IV drugs whose volume equated to millilitres to several decimal places, or doses that bore no relation to suppository strength were unreasonable. The marking scheme accepted a range of doses, and rounding up was not marked as wrong. I do not agree that doctors should be lazy and leave rounding doses to pharmacists. The strengths of solutions are available in the BNF and it is not a difficult task. Many less drug errors might occur if doctors took more care in prescribing, rather than relying on pharmacists to correct their errors.
I acknowledge that stress levels may have been high on the day of interview. However, doctors frequently prescribe in stressful environments, and all candidates were aware they were being assessed, which should have made them more fastidious than usual.
Finally, the prescribing station was part of an assessment centre in which candidates had to perform a number of tasks, including resuscitation of a newborn and child, interview, portfolio assessment and so forth. It is implied that the results from our prescribing station alone determined whether an individual was offered a job, but this was not the case. The centre created a complex picture of the candidates, and no candidate was offered or denied a job based on the prescribing station alone. We have also implemented extra teaching on prescribing skills to the doctors who were subsequently employed.
Unfortunately, letters require concise descriptions, and I can reassure Dr Wilson that the test and marking scheme were far from the crude assessment he describes.
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Conflict of Interest:
None declared.
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Published on: 24 June 2008
Off the top of their heads?
- Dylan M Wilson, Metabolic Fellow
While there can be no excuses for failing to sign, print, date, and recognise allergies, I do take issue with some points raised in this letter.
First, there is no mention of whether a BNF for Children was made available. It is a little unfair to criticise for incorrect doses if a suitable reference was not made available. While it could be argued that the doses of the drugs required to be prescribed are freque...
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While there can be no excuses for failing to sign, print, date, and recognise allergies, I do take issue with some points raised in this letter.
First, there is no mention of whether a BNF for Children was made available. It is a little unfair to criticise for incorrect doses if a suitable reference was not made available. While it could be argued that the doses of the drugs required to be prescribed are frequently encountered, the best of us still have blank moments. For example if one of the test subjects hadn't done a neonatal job for a while the loading and maintenance doses of phenobarbital could well have slipped out of their minds. Was this taken into account?
Second, if a trainee had sensibly rounded up/down a dose calculated for weight to aid the administration, was this counted as a black mark against correct dosing?
Third, it is not always possible to know what dose will actually aid administration, particularly with iv drugs, as doctors do not know every single drug's number of milligrams per ml. And nor should we. That would make us pharmacists. Pharmacists are good at being pharmacists.
Fourth, was unit variability taken into account? This affects doctors' prescribing. Some nurses are happy to give odd number doses. I have been asked to correct a dose I had rounded up back to the exact amount it worked out to be per kilogram. Different neonatal units have different gentamicin protocols. Different units prefer frequent (e.g. 1 or 2 hourly) salbutamol prescribed differently. For example one unit I worked in preferred it to be prescribed on the PRN side (rightly or wrongly) as there was more space, whereas another preferred it to take up the space of two or three drug boxes. What was your standard, and what makes your standard the correct one? This needs to be factored in.
Fifth, on the assumption that this was done on the day of their interviews, did you consider the nervousness and pressure the applicants were under on their application for ST posts given the complete mess that was MTAS? People probably prescribe better when they don't think their future career and livelihood depend on it.
These variables should be considered before people start employing or not employing people on the basis of a crude prescribing test.
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Conflict of Interest:
None declared.
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