Poor prescribing is continual
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7571.756-b (Published 05 October 2006) Cite this as: BMJ 2006;333:756
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Editor,
I agree that the recent debate about the undergraduate teaching of
clinical pharmacology, therapeutics, and prescribing is timely, and that
the suggestion in terms of a 'stocktake' from Aronson et al is in
principle worth exploring.
However, the present and future learning needs of existing
postgraduate prescribers, both medical and non-medical, are also in need
of consideration. Whilst an evidence-based approach is now an established
foundation of practice, clinicians face an information explosion, a
constant battle to recognise and then minimise their own cognitive biases
which may adversely affect their own perceptions of the evidence, a
rapidly changing health care environment with increasingly informed
patients and public and the inevitability of a finite set of health care
resources.
The recent publication of the GP Curriculum by the Royal College of
General Practitioners may in hindsight be seen as a watershed. Is it
possible to define the curriculum for clinical pharmacology, therapeutics,
and prescribing at undergraduate and postgraduate level? And as a result
establish a competency based approach?
The National Prescribing Centre would be a willing party to
discussions to establish feasibility.
Yours sincerely
Competing interests:
None declared
Competing interests: No competing interests
Editor - We read with considerable interest the editorial on medical
student teaching for better prescribing (1) and the subsequent letter
from the authors (2) which has set a challenge to a number of agencies to
consider practical measures to address the perceived problems.
Aronson and colleagues suggest that there should be joint
commissioning by interested parties of an independent systematic review of
the evidence relevant to prescribing and its teaching and assessment of
both graduates and undergraduates, and included the National Patient
Safety Agency as one of the interested parties.
It is indeed the case that the NPSA holds valuable data and
information relevant to medication safety within its National Reporting
and Learning System and has also actively contributed to the
implementation of safety within both undergraduate and post graduate
curricula. We would be delighted to contribute to any further discussion
and debate on this issue and to share any relevant data that might help
address it, including to the meeting to be convened by the GMC(3).
In terms of commissioning an independent systematic review, we
suggest that the Health Technology Assessment Programme of NHS R&D
National Institute for Health Research could take a lead on commissioning
this. Alternatively, this is a topic that could be addressed through the
Campbell Collaboration(4).
Professor Richard Thomson
Director of Epidemiology & Research
Professor David Cousins
Head of Safer Medication Practice
(1) Aronson JK, Henderson G,Webb DJ, Rawlins MD. A prescription for
better prescribing. BMJ 2006;333:459-60
(2) Aronson JK, Barnett DB,Ferner RE, Ferro A, Henderson G, Maxwell SR,
Rawlins MD, Webb DJ. Poor prescribing is continual. BMJ 2006;333:756
(3) Rubin P. Rubin P. A prescription for better prescribing. BMJ
2006;333:601
(4) http://www.campbellcollaboration.org/
Competing interests:
None declared
Competing interests: No competing interests
I am pleased that Aronson et al recognise the need for evidence to
inform the debate over prescribing and I note that they have broadened
their interest to include postgraduate education.
The General Medical Council Education Committee already has a good
deal of information relating to the undergraduate phase and is collecting
more through its ongoing research into how well its requirements,
described in Tomorrow’s Doctors, prepare new graduates for the Foundation
Programme and beyond.
However, there is a paucity of evidence relating to factors that
could improve the quality of prescribing in later stages of a doctor’s
training and career. There is a growing risk that this debate will
escalate in the wider media, where the underlying issues are not widely
understood, with resulting alarm to patients and the public about their
safety. It is essential that this perception does not become entrenched.
The GMC therefore strongly supports the value of acquiring such evidence
and will convene a meeting of interested parties to take this important
matter forward.
Professor Peter Rubin
Chairman, GMC Education Committee
Competing interests:
None declared
Competing interests: No competing interests
Getting postgraduate junior doctors to prescribe at all can be a “problem”-Australian experience.(Oct 2006)
Cutting down on medication errors, is one of the end
points(presumably) of better prescribing, yet almost impossible to achieve
if nurses administering intravenous medications have to beg for scripts
from doctors.
Problems seemed to start a few years ago in synchrony with; the
almost complete departure of consultants from wards, the change from a six
year medical degree to a four year postgraduate one, and the latest
version of themselves demonstrated by pharmacists, nurses, dieticians and
sundry health care associates.
Briefly, the RN has, several times in each shift, to call(page) the
ward call(junior doctor) to prescribe things like daily dose IV Gentamicin
for the infected patient, IV Heparin for the usually Warfarinised patient,
oral once daily Warfarin for the previously intravenously Heparinised
patient, oral Calcium supplementation for the postoperative thyroid
patient, and so on. For reasons unknown junior doctors are incapable of
using modern communication systems(computers/printers) to pass on/handover
the names and locations of those of their patients in the above categories
to other doctors.
The problem seems to “worsen” as follows. Because doctors are no
longer allowed to use “standing IV fluid orders” – by that I mean
repeating the previous flask of fluid from the same prescription- for nil
by mouth patients, they now have to be asked(paged) to “take an interest”
in the what mixture of crystalloids they would like the patient to have
next. And the doctors now seem willing to prescribe almost anything over
the phone without actually knowing the patient.And when I ask them, they
swear they are across the situation.
Competing interests:
None declared
Competing interests: No competing interests