A prescription for better prescribing

It's that time of year again. The new junior members of staff have arrived and the old anxiety emerges—are they well trained? In particular, are they properly trained in practical drug therapy and prescribing? We believe they may not be.

In July we drew attention, yet again, to what we and many others perceive to be a serious problem in British medicine—poor prescribing.^{w1 w2} We emphasised that deficiencies are not confined to the United Kingdom, and three days later the Institute of Medicine in the United States independently expressed similar concerns.^w3 The chairman of the medical academic staff committee of the British Medical Association later concurred,^w4 and the Healthcare Commission urged the NHS to improve prescribing.^w5

Evidence of poor prescribing in the UK is abundant. Effective treatments, such as angiotensin converting enzyme inhibitors for heart failure1 and statins for hyperlipidaemia,2 are often underprescribed. Prescription errors are common,3 especially when new doctors start work in hospitals.4 Approximately 6.5% of admissions to hospital are related to adverse drug reactions, with an associated mortality of 0.15%; this costs the NHS £466m (€692m, $881m) annually.5

The reasons for these errors are manifold.³⁶ Some relate to system failures. For example, why does every NHS hospital have its own inpatient prescribing sheet? There should be a single nationwide form.

Another fundamental problem is that medical students are not adequately instructed. In 1994, UK medical students received a median 61 hours of teaching related to pharmacology, clinical pharmacology, and therapeutics.7 Since then the numbers of pharmacologists and clinical pharmacologists in the UK (and thus the amount of teaching) have fallen.⁸⁹ In contrast, nurses seeking to obtain the Postgraduate Certificate in Prescribing from the University of Liverpool must complete a training course of 162 hours of theory and 90 hours of practice.^w6

Prescribing is becoming increasingly difficult, and the inherent risks of adverse reactions and interactions have increased. Modern drugs are pharmacologically complex, the population is ageing, and the use of polypharmacy is increasing. The root cause of prescribing errors among final year medical students is the lack of an integrated scientific and clinical knowledge base.10 Tomorrow's doctors need a firm grounding in the principles of pharmacology and clinical pharmacology, linked to practical therapeutics,11 so that they can weigh up the potential benefits and harms of treatment; understand the sources of variability in drug response; base prescribing decisions on sound evidence; and monitor drug effects appropriately. The British Pharmacological Society has developed a syllabus to ensure that medical students are adequately trained.12 It should be adopted by and implemented in all UK medical schools.

But it is not enough to teach prescribing skills—they must also be assessed. Drug therapy cuts across all medical practice, and modern medicines are too potent for the newly qualified graduate to be allowed to prescribe without providing evidence of competence. Students should not be allowed to compensate for poor performance in this high risk activity by good performances in other areas.

The box (see bmj.com) shows our practical prescription to improve prescribing.13

Pharmacologists and clinical pharmacologists should be expected to lead the way in providing the necessary teaching and assessments. However, there are too few of them to handle the entire burden. Their clinical colleagues should be encouraged to devote specific sessions to practical drug treatment, not least because other specialists and general practitioners will draw on and provide extra practical experience. Partnerships with other prescribers, such as pharmacists and nurses, might also be useful.

Medical students have expressed their desire for more teaching in practical drug therapy and prescribing.¹³¹⁴ They too can play their part by encouraging their medical schools to provide more tuition. Together with Simon Maxwell at the University of Edinburgh, Amy Heaton, a medical student, has prepared a short web based questionnaire that asks medical students how well their course prepares them for prescribing drugs (http://fs12.formsite.com/amyheaton/pharmacologytherapeutics/index.html). We encourage all medical students and doctors in their first foundation year to take a couple of minutes to fill it in. We also challenge all those involved in teaching students and training doctors to implement these proposals. After all, we shall all benefit from better prescribing.