... and poor prescribing is continual
An editorial should bring an important topic to readers’ attention,
engage their interest, elicit their support or make them defensive or even
angry, provoke them to react, and trigger debate. We are delighted that
the recent editorial on poor prescribing in the UK  has done all of
these things, judging from the rapid responses on bmj.com and the personal
e-mails and letters that we have received, in addition to recent press
coverage and the letters that that coverage has elicited. We are
especially grateful to the many correspondents who have supported the
views that we propounded, and in particular the clinical pharmacists, who
are keen to play their part in improving patient care by improving
prescribing. Their skills complement those of clinical pharmacologists,
with whom they should, and in some cases already do, form partnerships.
An editorial cannot be comprehensive. We did not discuss the
knowledge needed to make a good prescriber; we have done that elsewhere.
We did not try to cover all forms of unsuccessful prescribing, such as the
different types of underprescribing and overprescribing, inappropriate
prescribing, irrational prescribing, and prescribing errors; a few
examples highlighted the problems.
Nor did we give a thorough account of all the evidence. But we are
surprised that Professor Rubin  thinks that we provided no evidence at
all. We cited supporting evidence for our major statements, citations that
in turn contain further references to published evidence. We do not know,
any more than he does, how much teaching is required to achieve a minimum
desirable standard of prescribing proficiency, but we do not believe that
he, as a clinical pharmacologist, thinks that reducing the exposure that
medical students get to experts in the principles and practice of
prescribing will produce better prescribers, particularly at a time when
drug therapy is becoming increasingly complex. The fact that nurse
prescribers are exposed to more than four times the expert teaching that
clinical students receive on all forms of practical drug therapy gives us
much pause. It is not enough to have the laudable expectations to which
Professor Rubin refers — practical measures are needed to achieve them.
Rather than pursuing a debate in the limited amount of space that
editorials and letters afford, we have two further proposals, which we
hope will advance the discussion:
1. That interested parties, such as the General Medical Council, the
Postgraduate Medical Education and Training Board, the Audit Commission,
the Royal Colleges, the Council of the Heads of Medical Schools and Deans
of UK Faculties of Medicine, the National Patient Safety Agency, the
National Prescribing Centre, the British Pharmacological Society, the
Royal Pharmaceutical Society, and the Royal College of Nursing, should
jointly commission an independent systematic review of all the evidence
relevant to prescribing, its teaching and assessment, at both graduate and
undergraduate levels, in the UK and world wide, in order to synthesize
current knowledge, to identify important gaps, and to propose a set of
2. That those parties then hold an open symposium at which the
problems can be discussed in detail, and at which practical and
implementable solutions can be sought and further research proposed.
We look forward to their responses.
1. Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for
better prescribing. BMJ 2006; 333: 459-60 (2 September).
2. Rubin P. Medical education is a continuum. BMJ 2006; 333: 601 (16
Competing interests: No competing interests