Junior doctors prescribing: enhancing their learning in practice

The European List of Key Medicines for Medical Education: A Modified Delphi Study

Rational prescribing is essential for the quality of health care. However, many final-year medical students and junior doctors lack prescribing competence to perform this task. The availability of a list of medicines that a junior doctor working in Europe should be able to independently prescribe safely and effectively without supervision could support and harmonize teaching and training in clinical pharmacology and therapeutics (CPT) in Europe. Therefore, our aim was to achieve consensus on such a list of medicines that are widely accessible in Europe. For this, we used a modified Delphi study method consisting of three parts. In part one, we created an initial list based on a literature search. In part two, a group of 64 coordinators in CPT education, selected via the Network of Teachers in Pharmacotherapy of the European Association for Clinical Pharmacology and Therapeutics, evaluated the accessibility of each medicine in his or her country, and provided a diverse group of experts willing to participate in the Delphi part. In part three, 463 experts from 24 European countries were invited to participate in a 2-round Delphi study. In total, 187 experts (40%) from 24 countries completed both rounds and evaluated 416 medicines, 98 of which were included in the final list. The top three Anatomical Therapeutic Chemical code groups were (1) cardiovascular system (n = 23), (2) anti-infective (n = 21), and (3) musculoskeletal system (n = 11). This European List of Key Medicines for Medical Education could be a starting point for country-specific lists and could be used for the training and assessment of CPT.

Key aspects of teaching that affect perceived preparedness of medical students for transition to work: insights from the COVID-19 pandemic

BACKGROUND

The self-perceived preparedness of medical students to transition into practising junior doctors has implications for patient safety, graduate well-being and development of professional identity.

AIMS

To examine the impact of changes to final-year education and placements and determine key elements that contribute to self-perceived preparedness for transition to work.

METHODS

An online survey among final-year medical students at one Australian medical school in 2020 (the cohort most affected by the coronarvirus disease 2019 [COVID-19] pandemic), exploring overall self-perceived preparedness and specific competencies, including questions in previous Australian Medical Council/Medical Board of Australia annual national surveys. Quantitative and qualitative content analyses were performed.

RESULTS

Thirty-three percent of eligible participants completed the survey. There was a significant decline in overall self-perceived preparedness among participants (mean preparedness, 3.55 ± 0.88) compared with 2019 graduates from the same medical school (mean preparedness, 4.28 ± 0.64, P < 0.001) and the national average (mean preparedness, 3.81 ± 0.93, P = 0.04). There was a decline in self-perceived preparedness for all specific competencies, with complex competencies more greatly affected. Qualitative content analysis of free text responses identified limitations of an online compared with a face-to-face formal education program and specific aspects of placements, which contribute to perceived preparedness.

CONCLUSION

The current study highlights key aspects of clinical placements and formal teaching programs that contribute to perceptions of preparedness for transition to clinical practice. Relevant experiential learning in the clinical setting, opportunities for deliberate practice of necessary skills (in simulation and the clinical setting) and reflective opportunities from formal teaching programs contribute to perceived preparedness and are important elements to be included in the final phase of any medical program.

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study

CONTEXT

Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention.

METHODS

In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2).

RESULTS

Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order).

CONCLUSION

Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Knowledge, Attitudes and Practice Regarding Antibiotic Prescription by Medical Interns: A Qualitative Study in Spain

Antibiotic resistance is an issue of growing importance in the public health sphere. Medical interns are of great relevance when it comes to the source of this problem. This study therefore sought to ascertain which factors influence the management of antibiotic therapy by this population, in order to pinpoint the possible causes of misprescribing habits. We conducted a qualitative study based on focus group techniques, with groups consisting of medical interns from the Santiago de Compostela Clinical University Teaching Hospital. Our study identified factors which the participants considered to be determinants of antibiotic use and their relationship with the appearance of resistance. The single most repeated factor was the influence of the attending physician’s judgement; other factors included a high healthcare burden or prescribing inertia. This stage is an opportunity to correct misprescribing habits, by implementing educational interventions aimed at modifying the identified factors.

A simulation-based module in pharmacology education reveals and addresses medical students' deficits in leading prescription talks

Although doctor-patient communication is essential for drug prescription, the literature reveals deficits in this area. An educational approach at the Cologne medical faculty aims at identifying and addressing those deficits in medical students.Fifth-year medical students first conducted a simulated prescription talk spontaneously. Subsequently, the conversation was discussed with peer students. A pharmacist moderated the discussion based upon a previously developed conversation guide. Afterwards, the same student had the conversation again, but as if for the first time. Conversations were video-recorded, transcribed and subjected to quantitative content analysis. Four days after the simulation, the students who conducted the talk, those who observed and discussed it, and students who did neither, completed a written test that focused on the content of an effective prescription talk.Content analysis revealed clear deficits in spontaneously led prescription talks. Even essential information as on adverse drug reactions were often lacking. Prescription talks became clearly more informative and comprehensive after the short, guided peer discussion. With regard to a comprehensive, informative prescription talk, the written test showed that both the students who conducted the talk and those who only observed it performed clearly better than the students who did not participate in the educational approach.Deficits regarding prescription talks are present in 5^th year medical students. We provide an approach to both identify and address these deficits. It thus may be an example for training medical students in simulated and clinical environments like the EACPT recommended to improve pharmacology education.

Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates

CONTEXT

Work readiness is often described in terms of the clinical competence medical graduates bring to day 1 of internship. Despite being increasingly viewed as a key graduate outcome, work readiness has remained poorly defined.

OBJECTIVE

This narrative review draws on the international literature to explore how different research methods provide differing insight into what constitutes work readiness of medical graduates. From this, we explored contributory factors and developed a conceptual framework to better understand work readiness.

METHODS

Databases were searched using the terms including "ready," "readiness," "preparedness," "medical graduates," "intern," and "junior doctor." Information was summarized using a textual description template that included information on study setting, participants, methodologies, limitations, and key result areas (including measures/themes and study conclusions). Consensus discussions between authors led to the naming and understanding of the key themes.

RESULTS

Seventy studies were included in the review. Study participants included final-year medical students (n = 20), junior doctors early in internship (n = 24), and junior doctors late in internship or postgraduate year 2 and above (n = 23). Most studies explored work readiness through the retrospective self-report of the students and/or junior doctor participants. Quantitative research methods elaborated on key skills-based competencies, whereas qualitative research methods provided insight into key contextual and individual characteristics that contributed to preparedness.

CONCLUSIONS

Different research methods provided insight into competencies, as well as individual and contextual aspects, associated with preparedness for practice. The transition from university to clinical practice is significant and requires personal capability and confidence, as well as a supportive training context. Enabling students to engage authentically in clinical environments enhanced preparedness by promoting understanding of role and responsibility. Individual resilience is important, but contextual factors, including provision of adequate support and feedback, can enhance or subtract from feeling prepared. We propose a novel conceptual framework for better understanding work readiness.

European List of Essential Medicines for Medical Education: a protocol for a modified Delphi study

INTRODUCTION

Junior doctors are responsible for a substantial number of prescribing errors, and final-year medical students lack sufficient prescribing knowledge and skills just before they graduate. Various national and international projects have been initiated to reform the teaching of clinical pharmacology and therapeutics (CP&T) during undergraduate medical training. However, there is as yet no list of commonly prescribed and available medicines that European doctors should be able to independently prescribe safely and effectively without direct supervision. Such a list could form the basis for a European Prescribing Exam and would harmonise European CP&T education. Therefore, the aim of this study is to reach consensus on a list of widely prescribed medicines, available in most European countries, that European junior doctors should be able to independently prescribe safely and effectively without direct supervision: the European List of Essential Medicines for Medical Education.

METHODS AND ANALYSIS

This modified Delphi study will recruit European CP&T teachers (expert group). Two Delphi rounds will be carried out to enable a list to be drawn up of medicines that are available in ≥80% of European countries, which are considered standard prescribing practice, and which junior doctors should be able to prescribe safely and effectively without supervision.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Review Committee of VU University Medical Center (no. 2020.335) and by the Ethical Review Board of the Netherlands Association for Medical Education (approved project no. NVMO-ERB 2020.4.8). The European List of Essential Medicines for Medical Education will be presented at national and international conferences and will be submitted to international peer-reviewed journals. It will also be used to develop and implement the European Prescribing Exam.

A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting

AIMS

To explore the impact of a prescribing feedback intervention on insulin prescribing.

METHODS

This was a mixed-methods study in a hospital setting. An insulin prescribing feedback intervention was delivered verbally and in writing to twelve doctors. Insulin prescribing error frequency was compared to ten doctors who had not received the feedback intervention. Insulin prescribing was audited over four weeks at the start and end of the intervention period. Semi-structured interviews were conducted with participating doctors who had received feedback, and qualitative data analysed thematically to explore the impact of the intervention on their prescribing practice.

RESULTS

Prescribing data were collected on 370 insulin prescriptions with 241 errors identified. A significant reduction (χ2 = 22.6, p=<0.05) in insulin prescribing error frequency was observed in the intervention group, with a non-significant increase reported in the control group. Feedback was received positively and considered valuable by doctors, supporting development of their knowledge and skills and encouraging reflection on their prescribing performance. Doctors described enhanced confidence in insulin prescribing and a desire to improve as a prescriber and avoid harm, with feedback raising awareness of their development needs. Prescribers also described enhanced team work, with greater information and feedback seeking behavior to inform future prescribing decisions.

CONCLUSIONS

Feedback has potential to improve insulin prescribing and is a valued and acceptable process intervention for doctors. The impact on insulin prescribing practice is varied and complex influencing the capability, opportunity and motivation of prescribers to adapt and evolve their behavior in response to ongoing feedback.

Knowledge, attitude, and implementation of nicotine replacement therapy by dental and medical interns in Davangere city: A cross-sectional survey

Background:

One of the prime causes of illness and premature death is smoking. Almost 50% of smokers attempt to quit the habit; however, at most, 2%–3% achieve success. The rationale is that innumerable withdrawal attempts are unplanned, and the most effective cessation aids are unacquainted. Nicotine replacement therapy (NRT) is the most common cessation aid. Furthermore, motivation from dental and medical professionals can be effective for patients to quit smoking. The study aimed to assess the knowledge, attitude, and practice regarding the implementation of NRT among dental and medical interns in Davangere city.

Materials and Methods:

A questionnaire-based survey was conducted, which included 442 dental and medical interns from two dental and two medical colleges in Davangere city, Karnataka. The questionnaire included multiple-choice questions regarding knowledge, attitude, and implementation of NRT. The response rate of interns was 93.67%.

Results:

Among dental and medical interns, there was no statistically significant difference in knowledge about NRT with P = 0.976 (P > 0.05). However, a statistically significant difference existed regarding attitude and implementation in the interns about NRT among dental and medical interns with P = 0.001 (P < 0.05). Among dental and medical interns, dental interns had a positive attitude and implementation toward NRT than medical interns.

Conclusion:

The overview implicated that the dental interns had better vision than medical interns; however, both the groups' comprehension concerning NRT is scanty and advocates education about the fundamentals of NRT either via workshop or by continuing dental education programs.

Microbial Resistance Movements: An Overview of Global Public Health Threats Posed by Antimicrobial Resistance, and How Best to Counter

Antibiotics changed medical practice by significantly decreasing the morbidity and mortality associated with bacterial infection. However, infectious diseases remain the leading cause of death in the world. There is global concern about the rise in antimicrobial resistance (AMR), which affects both developed and developing countries. AMR is a public health challenge with extensive health, economic, and societal implications. This paper sets AMR in context, starting with the history of antibiotics, including the discovery of penicillin and the golden era of antibiotics, before exploring the problems and challenges we now face due to AMR. Among the factors discussed is the low level of development of new antimicrobials and the irrational prescribing of antibiotics in developed and developing countries. A fundamental problem is the knowledge, attitude, and practice (KAP) regarding antibiotics among medical practitioners, and we explore this aspect in some depth, including a discussion on the KAP among medical students. We conclude with suggestions on how to address this public health threat, including recommendations on training medical students about antibiotics, and strategies to overcome the problems of irrational antibiotic prescribing and AMR.

Twelve tips for facilitating medical students prescribing learning on clinical placement

Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.

Tackling Antimicrobial Resistance by promoting Antimicrobial stewardship in Medical and Allied Health Professional Curricula

INTRODUCTION

Antimicrobial resistance poses a serious threat to global health with significantly higher morbidity, mortality, and economic burden. This review aims to discuss the importance of the promotion of antimicrobial stewardship in medical and allied health professional curricula and training/educating tomorrow's doctors in combatting antimicrobial resistance. A narrative literature review was conducted to retrieve relevant information related to antimicrobial resistance and stewardship and their implications on medical and allied health professional education and training from searches of computerized databases, hand searches, and authoritative texts.

AREAS COVERED

Antimicrobial stewardship programs improve rational antibiotic use, reduce antimicrobial resistance, decrease complications of antibiotic use, and improve patient outcomes. Though health professional students recognize the importance and impact of antibiotic prescribing knowledge, many studies have consistently demonstrated low levels of confidence and competencies amongst students, highlighting that health professional schools failed to prepare them to prescribe antibiotics accurately.

EXPERT OPINION

There is an urgent call for the integration of antimicrobial stewardship teaching at the undergraduate level of medical education to train future prescribers on this critical aspect of public health. Proper undergraduate education on rational antibiotics use would enable health professional graduates to enter clinical practice with adequate competencies to become rational prescribers.

An Interactive Process for Delivering Pharmacologic Interventions for Migraine Headache to First-Year Medical Students

INTRODUCTION

This interactive didactic session is designed for first-year medical students to explore the common clinical symptom of headache and its various management strategies. The session provides an opportunity to cover a variety of drugs, mechanisms of action, drug-drug interactions, and routes of administration in a single 50-minute time frame.

METHODS

Using a modified case-based approach, we designed an interactive session for 41 first-year medical students. Students prepared for the session using basic learning objectives and a table of drugs that treat headache pain. In class, we distributed a patient scenario and a series of discussion questions to explore headache management. We assessed student performance using questions purchased from the National Board of Medical Examiners and student perceptions using both qualitative and quantitative data collected from faculty and end-of-block evaluations.

RESULTS

Student performance on purchased questions related to content was significantly increased when compared to the national average (n = 5; 90.6% ± 6.0% vs. 82.6% ± 8.5%; p = .0052). Student perceptions of the overall quality of the faculty, content presentation, and material were positive (4.4 out of 5.0). Two themes emerged in the end-of-block evaluations: Students commented positively on the prereading materials, and students commented on the need to address underlying physiology associated with the discussed pharmacology.

DISCUSSION

This flexible activity can be delivered in a short time (50 minutes) by a single faculty member in a variety of curricular structures. Our data demonstrate strong student performance and suggest that incorporating additional content would enhance delivery.

CerebroVis: Designing an Abstract yet Spatially Contextualized Cerebral Artery Network Visualization

Blood circulation in the human brain is supplied through a network of cerebral arteries. If a clinician suspects a patient has a stroke or other cerebrovascular condition, they order imaging tests. Neuroradiologists visually search the resulting scans for abnormalities. Their visual search tasks correspond to the abstract network analysis tasks of browsing and path following. To assist neuroradiologists in identifying cerebral artery abnormalities, we designed CerebroVis, a novel abstract-yet spatially contextualized-cerebral artery network visualization. In this design study, we contribute a novel framing and definition of the cerebral artery system in terms of network theory and characterize neuroradiologist domain goals as abstract visualization and network analysis tasks. Through an iterative, user-centered design process we developed an abstract network layout technique which incorporates cerebral artery spatial context. The abstract visualization enables increased domain task performance over 3D geometry representations, while including spatial context helps preserve the user's mental map of the underlying geometry. We provide open source implementations of our network layout technique and prototype cerebral artery visualization tool. We demonstrate the robustness of our technique by successfully laying out 61 open source brain scans. We evaluate the effectiveness of our layout through a mixed methods study with three neuroradiologists. In a formative controlled experiment our study participants used CerebroVis and a conventional 3D visualization to examine real cerebral artery imaging data to identify a simulated intracranial artery stenosis. Participants were more accurate at identifying stenoses using CerebroVis (absolute risk difference 13%). A free copy of this paper, the evaluation stimuli and data, and source code are available at osf.io/e5sxt.

Preparedness to prescribe antibiotics responsibly: a comparison between final year medical students in France and Sweden

Students should graduate from medical school feeling prepared to prescribe antibiotics responsibly. We assessed self-reported preparedness among students at medical schools in Europe, and we focus here on the results from students in Sweden and France, countries with wide differences in the intensity of antibiotic consumption and burden of antibiotic resistance. We conducted a cross-sectional web-based survey in 2015, based on a comprehensive set of topics related to prudent antibiotic use. All final year students at a medical school in France or Sweden were eligible to participate. Preparedness scores were calculated for each student, and mean scores were compared at medical school and country levels. Comparisons were also made on availability of teaching methods. We received responses from 2085/7653 (response rate 27.2%) students from 31/34 eligible medical schools in France and 302/1124 (26.9%) students from 7/7 schools in Sweden. The relative ranking order of curriculum topics by preparedness level was consistent between countries, but students in Sweden had higher self-reported levels of preparedness in 21/27 topics. There was higher availability for eight of nine teaching methods at Swedish medical schools. Students in France were more likely to report a need for further education on antibiotic use (63.5% vs. 20.3%, p < 0.001). Final year students in France report lower levels of preparedness, less availability of teaching methods and higher needs for more education on antibiotic use. Furthermore, we have identified specific areas for improvement in education on prudent antibiotic use in both Sweden and France.

Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education

AIMS

Prescribing is a core skill for junior doctors, yet 8-10% of their prescriptions contain errors. To ensure adequate training in prescribing, it is important to define the diseases for which junior doctors should be competent to prescribe. The aim of the present study was therefore to identify the essential diseases in prescribing for junior doctors.

METHODS

A two-round Delphi consensus study was conducted among medical specialists, general practitioners, junior doctors, pharmacists and pharmacotherapy teachers from all eight academic hospitals in the Netherlands. Using a five-point Likert scale, the participants indicated for each item on an initial questionnaire whether it should be considered an essential disease for junior doctors. The items for which ≥80% of all respondents agreed or strongly agreed were accepted as essential diseases.

RESULTS

Sixty-two participants completed the Delphi survey. In total, 63 of 220 items were considered to be essential diseases.

CONCLUSION

This is the first Delphi consensus study identifying exact conditions that junior doctors must be able to prescribe for. The essential diseases can be used for training in prescribing and assessment of junior doctors' prescribing competence.

Making it work: the feasibility and logistics of delivering large-scale interprofessional education to undergraduate healthcare students in a conference format

An interprofessional education conference was developed and delivered to undergraduate medical and pharmacy students to address training needs around appropriate antimicrobial prescribing, identification and management of sepsis, patient safety and interprofessional working. The day consisted of keynote lectures delivered by specialist speakers and three small group interprofessional teaching sessions exploring (1) the choice and prescribing of antimicrobials for a range of infections, (2) the diagnosis and management of sepsis utilising simulation methodology and (3) the discussion of a clinical error using significant event analysis. Students' attitudes and acceptance towards this educational intervention were assessed using a mixed methods evaluation. The delivery of an effective learning and teaching intervention in a conference format to a large cohort of pharmacy and medical students (n = 352) was found to be feasible. The logistics of organising an IPE conference of this scale were challenging but not insurmountable if sufficient staff and financial resources can be secured. Scheduling access to adequate teaching rooms and student timetabling were amongst the other important aspects affecting the success of such an event.

Do final-year medical students have sufficient prescribing competencies? A systematic literature review

Aims

Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate.

Methods

PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included.

Results

Twenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies.

Conclusions

There is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors.

Learning to prescribe through co-working: junior doctors, pharmacists and consultants

CONTEXT

Learning to prescribe is challenging for junior doctors. Significant efforts have been made to improve prescribing education, especially in view of the high rates of prescribing errors made by junior doctors. However, considerations of educational options often overlook the fact that learning to prescribe and prescribing practices rely on practice-based interactions with informed practitioners, such as pharmacists and consultants. Pharmacists have long made important contributions to developing prescribing capacities.

OBJECTIVES

The present study examines the potential of everyday co-working between junior doctors and pharmacists, in conjunction with consultants, as an accessible means of developing effective prescribing practices.

METHODS

A qualitative interview study was conducted in an Australian tertiary hospital using thematic analysis to explore junior doctors', pharmacists' and consultants' perspectives on how co-working supports learning to prescribe in an acute tertiary hospital setting. Participants included 34 practitioners, comprising junior doctors (n = 11), consultants (n = 10) and pharmacists (n = 13). The thematic analysis was informed by workplace learning theory.

RESULTS

Learning to prescribe was found to be a highly interdependent process. In particular, junior doctors were dependent on co-working with consultants and pharmacists. Three interrelated themes related to co-working and learning to prescribe in the workplace were identified: (i) prescribing readiness of junior doctors; (ii) need for guidance, and (iii) the challenges of pharmacists co-working as outsiders.

CONCLUSIONS

Co-working with pharmacists and consultants contributes positively to junior doctors' prescribing practices. However, co-working is complex and is influenced by differing understandings of prescribing practices. These insights assist in informing how co-working can be enacted routinely in hospital settings to promote safe and effective prescribing practices. Consideration should be given to when and how co-working between junior doctors and pharmacists is initiated, including during medical school. In clinical settings, strategies such as having pharmacists attend ward rounds and adopt a role of learning facilitation rather than error identification may augment everyday opportunities for co-working and learning.

Boosting clinical performance: The impact of enhanced final year placements

BACKGROUND

This study follows on from a study that investigated how to develop effective final year medical student assistantship placements, using multidisciplinary clinical teams in planning and delivery.

AIMS

This study assessed the effects on objective structured clinical examination (OSCE) performance of the in-course enhanced "super-assistantship" placement introduced to a randomly selected sample of 2013-14 final year medical students at Leeds medical school.

METHODS

Quantitative data analysis was used to compare the global grades of OSCE stations between students who undertook this placement against those who did not.

RESULTS

There was a small overall improvement in the "super-assistantship" student scores across the whole assessment (effect size = 0.085). "Pre-op Capacity", "Admissions Prescribing" and "Hip Pain" stations had small-medium effect sizes (0.226, 0.215, and 0.214) in favor of the intervention group. Other stations had small effect sizes (0.107-0.191), mostly in favor of the intervention group.

CONCLUSIONS

The "super-assistantship" experience characterized by increasing student responsibility on placement can help to improve competence and confidence in clinical decision-making "in a simulated environment". The clinical environment and multidisciplinary team must be ready and supported to provide these opportunities effectively. Further in-course opportunities for increasing final year student responsibility should be developed.

Developing junior doctors' prescribing practices through collaborative practice: Sustaining and transforming the practice of communities

Prescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors' prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists' contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors' prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.

How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014

OBJECTIVE

To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions.

DESIGN

A rapid review of the literature (registration #CRD42013005305).

DATA SOURCES

Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary research or studies reporting UK medical graduates' preparedness between 2009 and 2014: manuscripts in English; all study types; participants who are final-year medical students, medical graduates, clinical educators, patients or NHS employers and all outcome measures.

DATA EXTRACTION

At time 1, three researchers screened manuscripts (for duplicates, exclusion/inclusion criteria and quality). Remaining 81 manuscripts were coded. At time 2, one researcher repeated the process for 2013-2014 (adding six manuscripts). Data were analysed using a narrative synthesis and mapped against Tomorrow's Doctors (2009) graduate outcomes.

RESULTS

Most studies comprised junior doctors' self-reports (65/87, 75%), few defined preparedness and a programmatic approach was lacking. Six themes were highlighted: individual skills/knowledge, interactional competence, systemic/technological competence, personal preparedness, demographic factors and transitional interventions. Graduates appear prepared for history taking, physical examinations and some clinical skills, but unprepared for other aspects, including prescribing, clinical reasoning/diagnoses, emergency management, multidisciplinary team-working, handover, error/safety incidents, understanding ethical/legal issues and ward environment familiarity. Shadowing and induction smooth transition into practice, but there is a paucity of evidence around assistantship efficacy.

CONCLUSIONS

Educational interventions are needed to address areas of unpreparedness (eg, multidisciplinary team-working, prescribing and clinical reasoning). Future research in areas we are unsure about should adopt a programmatic and rigorous approach, with clear definitions of preparedness, multiple stakeholder perspectives along with multisite and longitudinal research designs to achieve a joined-up, systematic, approach to understanding future educational requirements for junior doctors.

Perceptions and Impact of Mandatory eLearning for Foundation Trainee Doctors: A Qualitative Evaluation

BACKGROUND

Junior doctors in the UK must complete various educational components during their two year Foundation training programme. It is important that mandatory learning is informative and engaging. The aim of this study was to evaluate trainee doctors' perceptions of a Technology Enhanced Learning (TEL) programme developed to improve prescribing competency.

METHOD

Focus groups and interviews were conducted at three hospital sites in the West Midlands. Codes, sub-themes and themes were determined using deductive and inductive thematic analysis.

RESULTS

Data were collected from 38 Foundation trainee doctors. Results revealed major themes relating to prescribing education, the user experience and user engagement. Key findings included the positive impact of preparedness following undergraduate education on the user experience of the TEL programme at the postgraduate level; the impact of content, structure, and individual learning needs and styles on the user experience; and the impact of motivation and time on engagement. Most trainees engaged with the programme owing to its mandatory nature; however, some trainees also used the programme voluntarily, for example, to acquire knowledge prior to starting a new placement.

CONCLUSIONS

It is important to ensure that learners are willing to engage with mandatory TEL, and that they have the time and motivation to do so. It is also important to ensure that learners have a positive user experience and that in designing TEL individual differences in learning styles and needs are taken into account. These findings have implications for educators and system developers in the construction and design of mandatory eLearning programmes.

Safe prescribing training provision for junior doctors: is this optimal?

BACKGROUND

The aim of this study was to determine the training provisions in practical safe prescribing for foundation doctors in NHS hospitals located in the South Thames region.

METHODS

A web-based questionnaire was distributed by e-mail to all 1762 foundation doctors in the South Thames Foundation School (STFS) region. In addition, a separate questionnaire was distributed to prescribing training Leads at 15 NHS Hospital Trusts. Quantitative data were analysed using descriptive statistics and thematic analysis was performed on qualitative data.

RESULTS

Trainers: 10 Prescribing Leads (67 %) responded. Of the 9 NHS Trusts that offered safe prescribing training in their induction programme, 5 included a practical prescribing session. By the end of the foundation year, 6 NHS Trusts had provided at least one dedicated practical prescribing session for F1s compared with 2 NHS Trusts for F2s. Trainees: A total of 124 foundation trainees (7.2 %) responded (69 F1s and 55 F2s). 87 % of F1s received dedicated training in safe prescribing at their Trust induction (n = 60) in comparison to 49 % of F2s (n = 27). 80 % of F1s (n = 55) had a practical prescribing session during induction versus 27 % of F2s (n = 15). The difference was significant, X (2) (1, N = 124) = 34.23, p <0.0001. Emerging themes from qualitative data included, recognition of medical education as a continuum, importance of working relationships with pharmacists and neglect of F2s.

CONCLUSIONS

There appears to be a lack of emphasis on the training of F2 doctors in practical safe prescribing compared with F1 doctors. There should be standardisation of safe prescribing training provisions, particularly in the induction period and for F2 doctors.

An evaluation of UK foundation trainee doctors' learning behaviours in a technology-enhanced learning environment

BACKGROUND

Technology-Enhanced Learning (TEL) can be used to educate Foundation Programme trainee (F1 and F2) doctors. Despite the advantages of TEL, learning behaviours may be exhibited that are not desired by system developers or educators. The aim of this evaluation was to investigate how learner behaviours (e.g. time spent on task) were affected by temporal (e.g. time of year), module (e.g. word count), and individual (e.g. knowledge) factors for 16 mandatory TEL modules related to prescribing and therapeutics.

METHODS

Data were extracted from the SCRIPT e-Learning platform for first year Foundation trainee (F1) doctors in the Health Education England's West Midland region from 1(st) August 2013 to 5(th) August 2014. Generalised Estimating Equation models were used to examine the relationship between time taken to complete modules, date modules were completed, pre- and post-test scores, and module factors.

RESULTS

Over the time period examined, 688 F1 doctors interacted with the 16 compulsory modules 10,255 times. The geometric mean time taken to complete a module was 28.9 min (95% Confidence Interval: 28.4-29.5) and 1,075 (10.5%) modules were completed in less than 10 min. In February and June (prior to F1 progression reviews) peaks occurred in the number of modules completed and troughs in the time taken. Most modules were completed, and the greatest amount of time was spent on the learning on a Sunday. More time was taken by those doctors with greater pre-test scores and those with larger improvements in test scores.

CONCLUSIONS

Foundation trainees are exhibiting unintended learning behaviours in this TEL environment, which may be attributed to several factors. These findings can help guide future developments of this TEL programme and the integration of other TEL programmes into curricula by raising awareness of potential behavioural issues that may arise.

Prescription Writing in Small Groups as a Clinical Pharmacology Educational Intervention: Perceptions of Preclerkship Medical Students

Medical students do not perform well in writing prescriptions, and the 3 variables-learner, teacher, and instructional method-are held responsible to various degrees. The objective of this clinical pharmacology educational intervention was to improve medical students' perceptions, motivation, and participation in prescription-writing sessions. The study participants were second-year medical students of the College of Medicine and Medical Sciences of the Arabian Gulf University, Bahrain. Two prescription-writing sessions were conducted using clinical case scenarios based on problems the students had studied as part of the problem-based learning curriculum. At the end of the respiratory system subunit, the training was conducted in small groups, each facilitated by a tutor. At the end of the cardiovascular system subunit, the training was conducted in a traditional large-group classroom setting. Data were collected with the help of a questionnaire at the end of each session and a focus group discussion. A majority of the students (95.3% ± 2.4%) perceived the small-group method better for teaching and learning of all aspects of prescription writing: analyzing the clinical case scenario, applying clinical pharmacology knowledge for therapeutic reasoning, using a formulary for searching relevant prescribing information, and in writing a complete prescription. Students also endorsed the small-group method for better interaction among themselves and with the tutor and for the ease of asking questions and clarifying doubts. In view of the principles of adult learning, where motivation and interaction are important, teaching and learning prescription writing in small groups deserve a serious consideration in medical curricula.

Preparing to prescribe: How do clerkship students learn in the midst of complexity?

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used mixed methods to explore how undergraduate medical students learn to prescribe in the 'real world'. It was informed by cognitive psychology, sociocultural theory, and systems thinking. We found that learning to prescribe occurs as a dynamic series of socially negotiated interactions within and between individuals, communities and environments. As well as a thematic analysis, we developed a framework of three conceptual spaces in which learning opportunities for prescribing occur. This illustrates a complex systems view of prescribing education and defines three major system components: the "social space", where the environmental conditions influence or bring about a learning experience; the "process space", describing what happens during the learning experience; and the intra-personal "cognitive space", where the learner may develop aspects of prescribing expertise. This conceptualisation broadens the scope of inquiry of prescribing education research by highlighting the complex interplay between individual and social dimensions of learning. This perspective is also likely to be relevant to students' learning of other clinical competencies.

Using concept mapping to evaluate knowledge structure in problem-based learning

BACKGROUND

Many educational programs incorporate problem-based learning (PBL) to promote students' learning; however, the knowledge structure developed in PBL remains unclear. The aim of this study was to use concept mapping to generate an understanding of the use of PBL in the development of knowledge structures.

METHODS

Using a quasi-experimental study design, we employed concept mapping to illustrate the effects of PBL by examining the patterns of concepts and differences in the knowledge structures of students taught with and without a PBL approach. Fifty-two occupational therapy undergraduates were involved in the study and were randomly divided into PBL and control groups. The PBL group was given two case scenarios for small group discussion, while the control group continued with ordinary teaching and learning. Students were asked to make concept maps after being taught about knowledge structure. A descriptive analysis of the morphology of concept maps was conducted in order to compare the integration of the students' knowledge structures, and statistical analyses were done to understand the differences between groups.

RESULTS

Three categories of concept maps were identified as follows: isolated, departmental, and integrated. The students in the control group constructed more isolated maps, while the students in the PBL group tended toward integrated mapping. Concept Relationships, Hierarchy Levels, and Cross Linkages in the concept maps were significantly greater in the PBL group; however, examples of concept maps did not differ significantly between the two groups.

CONCLUSIONS

The data indicated that PBL had a strong effect on the acquisition and integration of knowledge. The important properties of PBL, including situational learning, problem spaces, and small group interactions, can help students to acquire more concepts, achieve an integrated knowledge structure, and enhance clinical reasoning.

Which non-technical skills do junior doctors require to prescribe safely? A systematic review

AIMS

Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings.

METHODS

A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data.

RESULTS

A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed.

CONCLUSIONS

This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.

The Study of Prescribing Errors Among General Dentists

INTRODUCTION

In dentistry, medicine often prescribed to relieve pain and remove infections .Therefore, wrong prescription can lead to a range of problems including lack of pain, antimicrobial treatment failure and the development of resistance to antibiotics.

MATERIALS & METHODS

In this cross-sectional study, the aim was to evaluate the common errors in written prescriptions by general dentists in Kermanshah in 2014. Dentists received a questionnaire describing five hypothetical patient and the appropriate prescription for the patient in question was asked. Information about age, gender, work experience and the admission in university was collected. The frequency of errors in prescriptions was determined. Data by SPSS 20statistical software and using statistical t-test, chi-square and Pearson correlation were analyzed (0.05> P).

RESULTS

A total of 180 dentists (62.6% male and 37.4% female) with a mean age of 8.23 ± 39.199 participated in this study. Prescription errors include the wrong in pharmaceutical form (11%), not having to write therapeutic dose (13%), writing wrong dose (14%), typos (15%), error prescription (23%) and writing wrong number of drugs (24%). The most frequent errors in the administration of antiviral drugs (31%) and later stages of antifungal drugs (30%), analgesics (23%) and antibiotics (16%) was observed. Males dentists compared with females dentists showed more frequent errors (P=0.046). Error frequency among dentists with a long work history (P>0.001) and the acceptance in the university except for the entrance examination (P=0.041) had a statistically significant relationship.

CONCLUSION

This study showed that the written prescription by general dentists examined contained significant errors and improve prescribing through continuing education of dentists is essential.

Knowledge and Perceptions Regarding Nicotine Replacement Therapy among Dental Students in Karnataka

BACKGROUND

Organized dentistry has recognized the role of oral health professionals in discouraging tobacco use. Unexplored level of knowledge regarding the benefits and prescription of nicotine replacement therapy (NRT) have aroused interest among us which initiated us to assess the knowledge and perception of dental students toward NRT among various dental colleges in Karnataka, South India.

MATERIALS AND METHODS

A questionnaire survey was done among 16 selected colleges in Karnataka. It was distributed for 3(rd) year, final year, and interns. The study group provided answers to 14 item close-ended questionnaire. The first dimension obtained information on sex, age, course and year of study, and other dimension on forms in which NRT's are supplied, effectiveness of NRT's, side effects of NRT's, rate of success of NRT's, electronic cigars, and recommendations of NRT's. Statistical analysis was done using frequency distribution of responses.

RESULTS

A total of 1984 undergraduate students from Dental Colleges in Karnataka responded to the questionnaire. Most of the students were unaware about NRT term and its forms. Most of the students were aware about the effectiveness of NRT's (54%) for the rescue of the smokers to quit and felt transdermal patch (42%) could be the most effective way for smokers to quit followed by chewing gums, respectively. More than half of the respondents (53.5%) were unaware of E-cigar's and also felt that NRT's and Counseling cumulatively can contribute for cessation of the tobacco habit.

CONCLUSION

A large proportion of dental students in this part of the country were unaware about NRT.

Teaching safe prescribing to medical students: perspectives in the UK

Prescribing is a characteristic role of a medical practitioner. On graduating from medical school, students are presumed to have acquired the necessary pharmacology knowledge underpinning the therapeutics and developed their personal skills and behaviors in order to write a safe and effective prescription (The Four Ps). However, there are reports of errors in medical prescribing and dissatisfied feedback from recent graduates, which evidence potential flaws in the current training in the practice of prescribing. We examine the Four Ps from a systems approach and offer scope for educators and curriculum designers to review and reflect on their current undergraduate teaching, learning, and assessment strategies in a similar manner. We also adopt a national framework of common competencies required of all prescribers to remain effective and safe in their area of practice as a more objective layer to the broader learning outcomes of the General Medical Council Tomorrow's Doctors 2009. This exercise demonstrates where standard, recognized competencies for safe prescribing can be accommodated pedagogically within existing medical curricula.

Self-reported confidence in prescribing skills correlates poorly with assessed competence in fourth-year medical students

The objective of this study was to investigate the relationship between students' self-reported confidence and their objectively assessed competence in prescribing. We assessed the competence in several prescribing skills of 403 fourth-year medical students at the VU University Medical Center, the Netherlands, in a formative simulated examination on a 10-point scale (1 = very low; 10 = very high). Afterwards, the students were asked to rate their confidence in performing each of the prescribing skills on a 5-point Likert scale (1 = very unsure; 5 = very confident). Their assessments were then compared with their self-confidence ratings. Students' overall prescribing performance was adequate (7.0 ± 0.8), but they lacked confidence in 2 essential prescribing skills. Overall, there was a weak positive correlation (r = 0.2, P < .01, 95%CI 0.1-0.3) between reported confidence and actual competence. Therefore, this study suggests that self-reported confidence is not an accurate measure of prescribing competence, and that students lack insight into their own strengths and weaknesses in prescribing. Future studies should focus on developing validated and reliable instruments so that students can assess their prescribing skills.

Junior doctor-led 'near-peer' prescribing education for medical students

AIMS

Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors.

METHODS

One hundred and ninety-six tutorials were delivered to 183 students during 2010-2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis.

RESULTS

The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors.

CONCLUSIONS

A 'near-peer' junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials.

The effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine: an exploratory study

PURPOSE

The aim of this study is to evaluate the effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine.

METHODS

Between 2001 and 2007, 164 medical students took part in the prospective explorative study during their clinical clerkship in internal medicine at the VU University Medical Center, Amsterdam, The Netherlands. In a fixed order, each student had to formulate a treatment plan for a real patient in three situations of increasing realism: a minimal level (studying a patient record), medium level (preparing for a therapeutic consultation), and optimal level (preparing for and performing a therapeutic consultation with the patient).

RESULTS

In comparison to studying a patient record (minimal context level), preparing a therapeutic consultation (medium context) improved four of the six steps of the WHO six-step plan. Preparing and performing a therapeutic consultation with a real patient (optimal context) further improved three essential prescribing competencies, namely checking for contraindications and interactions, prescription writing, and instructions to the patient.

CONCLUSION AND RECOMMENDATIONS

The results of this first explorative study suggest that enrichment of the learning context (responsibility for patient care) might be an important factor to improve the training of rational prescribing skills of medical students during their clinical clerkship in internal medicine. Clinical (pharmacology) teachers should be aware that seemingly small adaptations in the learning context of prescribing training during clinical clerkships (i.e., with or without involvement with and responsibility for patient care) may have relatively large impact on the development of prescribing competencies of our future doctors.

The relationship between medical student learning opportunities and preparedness for practice: a questionnaire study

BACKGROUND

Alongside providing a knowledge base and practical skills, undergraduate medical education must prepare graduates to immediately begin practice as qualified doctors. A significant challenge is to provide safe learning opportunities that will optimise students' preparedness to start work. This study examined UK graduates' preparedness for clinical practice, and their exposure to real-life and simulated immediate care scenarios during final year placements.

METHOD

A questionnaire measuring students' perceived preparedness, and their exposure to immediate care scenarios, was distributed to all new Foundation Year 1 doctors (F1s) attending an induction session in one region of the UK.

RESULTS

356 F1s responded to the questionnaire (91% response rate; 89% of cohort) and data from 344 graduates of UK medical schools were analysed. Respondents were generally prepared for practice, but many reported few 'hands-on' experiences of providing immediate care during final year placements (a median of 1-2 experiences).Those who had 1-2 experiences reported no greater preparedness for acute management than those reporting no experience. Several exposures are necessary for a significant increase in perceived preparedness. Real-life experience was a better predictor of preparedness than simulated practice.

CONCLUSIONS

Gaps still remain in medical students' acute care experience, with a direct relationship to their perceived preparedness. The format and facilitation of placements may need to be addressed in order to enhance the quality of experience during final year.

Junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of errors

AIMS

The aim of the study was to explore and compare junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors.

METHODS

A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura's Social Cognitive Theory and Human Error Theory (HET).

RESULTS

Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2-12.4)] than F2s [4.0 IQR (0-10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001).

CONCLUSION

Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.

A randomised controlled trial of extended immersion in multi-method continuing simulation to prepare senior medical students for practice as junior doctors

BACKGROUND

Many commencing junior doctors worldwide feel ill-prepared to deal with their new responsibilities, particularly prescribing. Simulation has been widely utilised in medical education, but the use of extended multi-method simulation to emulate the junior doctor experience has rarely been reported.

METHODS

A randomised controlled trial compared students who underwent two, week-long, extended simulations, several months apart (Intervention), with students who attended related workshops and seminars alone (Control), for a range of outcome measures.

RESULTS

Eighty-four third year students in a graduate-entry medical program were randomised, and 82 completed the study. At the end of the first week, Intervention students scored a mean of 75% on a prescribing test, compared with 70% for Control students (P = 0.02) and Intervention teams initiated cardiac compressions a mean of 29.1 seconds into a resuscitation test scenario, compared with 70.1 seconds for Control teams (P < 0.01). At the beginning of the second week, an average of nine months later, a significant difference was maintained in relation to the prescribing test only (78% vs 70%, P < 0.01).At the end of the second week, significant Intervention vs Control differences were seen on knowledge and reasoning tests, a further prescribing test (71% vs 63% [P < 0.01]) and a paediatric resuscitation scenario test (252 seconds to initiation of fluid resuscitation vs 339 seconds [P = 0.05]).

CONCLUSIONS

The study demonstrated long-term retention of improved prescribing skills, and an immediate effect on knowledge acquisition, reasoning and resuscitation skills, from contextualising learning activities through extended multi-method simulation.

Medicine prescription practices of homeopathic undergraduate students in West Bengal, India

OBJECTIVE

To our knowledge, prescription of homeopathic medicines by homeopathic undergraduate students has not been studied before though it may possess serious implications. We aimed to determine the practice and attitudes of prescription by homeopathic undergraduate students.

METHODS

A cross-sectional study was carried out involving all the students from four government homeopathic schools of West Bengal, India. Ethical requirements were ensured and data were collected using self-administered questionnaires. Chi-square tests and logistic univariate regression analyses were performed to identify associations and differences.

RESULTS

A total of 328 forms were completed. Of these, 264 (80.5%) homeopathic undergraduate students admitted of prescribing medicines independently and most (40.5%) said that they did this 2-3 times a year. The most common reasons for this were 'urgency of the problem' (35.2%), 'previous experience with same kind of illness' (31.8%), and 'the problem too trivial to go to a doctor' (25.8%). About 63.4% of the students thought that it was alright to independently diagnose an illness while 51.2% thought that it was alright for them to prescribe medicines to others. Common conditions encountered were fever, indigestion, and injury. Students who prescribed medicines were more likely to belong to Calcutta Homeopathic Medical College and Hospital (odds ratio = 5.8; 95% confidence interval 2.247-14.972). Prescription by students gradually increased with academic years of homeopathic schools. Many students thought it was alright for students to diagnose and treat illnesses.

CONCLUSION

Prescription of medicines by homeopathic undergraduate students is quite rampant and corrective measures are warranted.

The effects of contributing to patient care on medical students' workplace learning

CONTEXT

Previous research has suggested that as medical students become more senior, they should increasingly take on the roles they will enact as newly qualified doctors by contributing to patient care. However, student contribution to patient care carries inherent risks to patient safety. This study aimed to provide students with a new opportunity to contribute to patient care and to use this as a platform from which to explore the influence of contributing to patient care on medical student learning.

METHODS

This study took place in the context of final-year medical student prescribing education at the University of Edinburgh, Edinburgh, UK. Students on attachment at a district general hospital were afforded a unique opportunity to learn prescribing by completing in-patient drug charts in a process termed 'pre-prescribing'. All students were invited to participate in focus groups conducted by the principal researcher. Focus group discussions were audio-recorded, transcribed verbatim and thematically analysed.

RESULTS

Six focus groups, each lasting 20-50 minutes, were conducted with four to seven participants (33 students in total). The emerging themes took the form of developmental outcomes and learning processes. Developmental outcomes included ability to perform the task, modification of attitudes towards the task, formation of a professional identity, and development of relationships within the team. The central feature of the experience which influenced all developmental outcomes, was making mistakes. The themes interact in complex ways and all contribute towards development as a professional.

CONCLUSIONS

This study has demonstrated that contributing to patient care enhances students' development as professionals. Some of these developmental outcomes, such as improvements in knowledge and skills, may be achievable to some extent within the classroom. Other changes, such as developing relationships, forming a sense of professional identity and modifying attitudes, might arguably be achievable only within the context of contributing to patient care.

Rational pharmacotherapy training for fourth-year medical students

Objectives:

In this study we aimed to evaluate the impact of Rational Pharmacotherapy (RPT) course program, reinforced by video footages, on the rational pharmacotherapy skills of the students.

Materials and Methods:

RPT course program has been conducted in Dokuz Eylul University School of Medicine since 2008/9. The course has been organised in accordance with World Health Organisation (WHO) Good Prescribing Guide. The aim of the course was to improve the problem solving skills (methodology for selection of the (p)ersonel-drug, prescription writing and informing patient about his illness and drugs) and communication skills of students. The impact of the course has been measured by pre/post-test design by an objective structured clinical examination (OSCE). In academic year 2010/11, to further improve OSCE score of the students we added doctor-patient communication video footages to the RPT course programme. During training, the students were asked to evaluate the doctor-patient communication and prescription on two video footages using a checklist followed by group discussions.

Results:

Total post-test OSCE score was significantly higher for 2010/11 academic year students (n = 147) than it was for 2009/10 year students (n = 131). The 2010/11 academic year students performed significantly better than the 2009/10 academic year students on four steps of OSCE. These steps were “defining the patient's problem”, “specifying the therapeutic objective”, “specifying the non-pharmacological treatment” and “choosing a (drug) treatment, taking all relevant patient characteristics into account”.

Conclusions:

The present study demonstrated that the implementation of video footages and group discussions to WHO/Good Prescribing Method improved the fourth-year medical students’ performance in rational pharmacotherapy skills.

A comparison of the reliability of smartphone apps for opioid conversion

BACKGROUND

Many medical professionals use smartphone applications (apps) on a daily basis to support clinical decision making. Opioid switching (conversion of one opioid to another at equianalgesic dose) is common in clinical practice and often challenging for doctors. Apps providing an opioid conversion tool can therefore be a useful resource. Despite rapid growth in the use of medical apps, the lack of robust regulation and peer review to ensure the accuracy and reliability of app content is currently an area of concern.

METHOD

We searched major online app stores for apps providing an opioid dose conversion tool. We assessed output variability between apps in the dose calculation of seven opioid switches, as well as assessing the level of professional medical involvement in the authorship, creation and design of the apps.

RESULTS

Of 23 different apps identified, more than half (n = 12; 52 %) had no stated medical professional involvement and only 11 (48 %) apps provided direct references to primary sources for their opioid conversion ratios. Conversion of 1 mg of oral morphine to oral codeine demonstrated the largest conversion output range (median 6.67 mg, range 3.333-12 mg). Conversion of 1 mg of oral morphine to methadone ranged from 0.05-0.67 mg, with only 44 % of methadone-converting apps (n = 4) commenting that the conversion ratio changes with magnitude of methadone dose. Overall, 35 % of apps (n = 8) did not warn the user about the standard practice of dose reduction when opioid switching. There was a statistically significant difference in the mean conversion output for hydromorphone (oral) between apps with and without medical professional involvement (0.2256 vs 0.2536; p = 0.0377).

CONCLUSIONS

There are significant concerns with regard to the reliability of information provided by apps offering opioid dose conversion, with lack of information regarding evidence-based content and peer review in many cases. It is crucial that better regulation of medical apps is instigated in order to ensure that patient safety is maintained.