David J. Brinkman

Essential competencies in prescribing: A first european cross‐sectional study among 895 final‐year medical students

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final‐year medical students across Europe. In a cross‐sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final‐year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final‐year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

The Prescribing Performance and Confidence of Final-Year Medical Students

It is widely believed that medical students are not as well prepared or as sufficiently skilled in prescribing as they should be at the outset of their careers. However, a preclinical context‐learning pharmacotherapy program has been found to improve students’ therapeutic skills during an ensuing clinical clerkship in internal medicine. 1 In this Commentary, we argue that a similar approach during a clinical clerkship may further enhance therapeutic skills at the end of the clerkship.

Key learning outcomes for clinical pharmacology and therapeutics education in Europe: a modified Delphi study

Harmonizing clinical pharmacology and therapeutics (CPT) education in Europe is necessary to ensure that the prescribing competency of future doctors is of a uniform high standard. As there are currently no uniform requirements, our aim was to achieve consensus on key learning outcomes for undergraduate CPT education in Europe. We used a modified Delphi method consisting of three questionnaire rounds and a panel meeting. A total of 129 experts from 27 European countries were asked to rate 307 learning outcomes. In all, 92 experts (71%) completed all three questionnaire rounds, and 33 experts (26%) attended the meeting. 232 learning outcomes from the original list, 15 newly suggested and 5 rephrased outcomes were included. These 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively. We provide a blueprint of a European core curriculum describing when and how the learning outcomes might be acquired.

Does Medical Students Knowing More About Drugs Lead to Better Treatment Choices

Prescribing errors are common in hospitals and can lead to extended hospitalization and significant morbidity and mortality. Many of these errors are made by junior doctors,1 partly because they lack competence in clinical pharmacology and therapeutics when they graduate. Although there is currently a shift toward more context-based learning, clinical pharmacology and therapeutics education is traditionally focused on the acquisition of factual drug knowledge rather than the acquisition of skills such as therapeutic reasoning and prescription writing. However, does more factual knowledge improve treatment choices? We investigated the relationship between factual drug knowledge and treatment appropriateness by reanalyzing data from a previous study involving 895 final-year medical students from 17 medical schools in 15 European countries.2 In that study, students’ knowledge was evaluated using multiple-choice questions focusing on factual drug knowledge (ie, working mechanism, side effects, and contraindications and interactions) that every student should know before graduation. Students also had to draw up a treatment plan for common clinical case scenarios that medical graduates should knowhow to treat, namely, acute bronchitis, gastroesophageal reflux disease, community-acquired pneumonia, osteoarthritis, and essential hypertension. Knowledge scores were expressed as a percentage of the maximum score (0% to 100%). For each clinical case the research team scored the treatment plan 1 to 3 (1 = inappropriate, 2 = suboptimal, 3 = appropriate). Overall treatment appropriateness was calculated as the mean score of the clinical case scenarios. We used the Spearman correlation coefficient (rs) to evaluate the relationship between knowledge and treatment scores. Overall, there was a significant but weak positive correlation (rs = 0.31, 95% P < .001) between drug knowledge and treatment appropriateness. This weak positive correlation suggests that students’ factual drug knowledge has little influence on the appropriateness of their treatment choices, which is consistent with previous studies showing a poor correlation between drug knowledge and the quality of treatment choices among general practitioners3 and recently graduated doctors.4 A possible explanation for these findings is that making an appropriate treatment choice is a cognitive skill that requires various high-level cognitive processes. In order to acquire this complex skill, medical students should be trained in a step-bystep manner, for example, by using the WHO Guide to Good Prescribing.5 In this model, medical students are explicitly trained to verify the suitability of their treatment choice for a particular patient. Although some factual drug knowledge is required in order to choose an appropriate treatment, it may play a less important role than previously assumed. Simply acquiring knowledge does not guarantee an appropriate treatment choice. Because clinical pharmacology and therapeutics education in Europe is still mainly based on the acquisition of factual knowledge by means of lectures and written examinations,6 more emphasis should be given to the training and assessment of prescribing skills in undergraduate medical curricula. For example, prescribing skills can be trained in preprescribing courses and student-run clinics, preferably as early in the curriculum as possible. By shifting the focus to prescribing skills rather than knowledge acquisi-

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.

What should Junior Doctors Know about the Drugs they frequently prescribe? A Delphi Study among Physicians in The Netherlands

The aim of this study was to identify the information about commonly prescribed drugs that junior doctors should know in order to prescribe rationally in daily practice, defined as essential drug knowledge (EDK). A two‐round Internet Delphi study was carried out involving general practitioners from one practice cluster, and registrars and consultants from two Dutch academic and eight teaching hospitals. A preliminary list of 377 potential EDK items for three commonly prescribed drugs was assessed on a dichotomous scale; an item was considered EDK if at least 80% consensus was reached. The consensus list of EDK items was discussed by the research team to identify similarities between the three drugs, with a view to forming a list of general EDK items applicable to other commonly prescribed drugs. Sixty experts considered 93 of the 377 items (25%) as EDK. These items were then used to form a list of 10 general EDK items. The list of EDK items identified by primary and secondary care doctors could be used in medical curricula and training programmes and for assessing the prescribing competence of future junior doctors. Further research is needed to evaluate the generalizability of this list for other commonly prescribed drugs.

Contextualizing patient care: opportunities for pharmacotherapy education

Dear Editor, The famous physician William Osler once wrote: ‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’. Although this statement was written in the late nineteenth century, inattention to the patient context is still a frequent and under-recognized cause of medical errors [1]. Especially concerning the prescribing of drugs, physicians often forget to take the circumstances and needs of individual patients (e.g. economic situation, social support) into account [2]. So, what is the cause? We think that one of the main reasons is that psychological, social, cultural, behavioural and economic factors that influence human health are often not integrated within the undergraduate medical education. Therefore, greater emphasis should be given to the patient context in the teaching and assessment of pharmacotherapy during the medical curriculum, from the first year onwards, by means of practical case-based training. The patient context is important when teaching medical students pharmacotherapy but its relevance is often overshadowed by the mantra of guideline adherence. Medical students are usually taught to strictly follow treatment guidelines, based on research evidence, and their adherence to these guidelines is subsequently assessed during examinations. Hence, little attention is paid to whether the treatment is suitable for the individual patient. This can lead to inappropriate prescribing and patient harm. For instance, prescribing a first-choice diuretic to an older hypertensive patient with poor mobility and vision will prompt more frequent urination and may increase the risk of falls, especially at night. Or, prescribing a complex dosage schedule to a patient with cognitive impairment and little social support may lead to low drug adherence. We recommend the use of the WHO 6-step method to train students to conceptualize their treatment plan (see example in Table 1) [3]. This method uses a rational approach in choosing drug treatment for individual patients and trains students to verify the suitability of various treatment alternatives according to four criteria: efficacy, safety, patient’s opinion and costs. By focusing on these criteria, students learn to tailor their treatment plans to the patient’s situation. Another way to improve students’ ability to conceptualize care is to offer them more experience and responsibility in prescribing drugs to real patients in clinical practice, preferably as early as possible during their medical training. This ‘learning by doing’ should be done under supervision and with feedback, as occurs in student-run clinics [5]. Because students tend to learn to prescribe by example, supervisors should emphasize the importance of the patient context when prescribing to patients. We think that teaching students to individualize their treatment plan for each patient is just as important as teaching the basic principles of pharmacokinetics and pharmacodynamics. In * David J. Brinkman d.brinkman@vumc.nl

Evaluating pharmacotherapy education: urgent need for hard outcomes

Recently, a call was made for more high-quality articles on clinical pharmacology and therapeutics (CPT) education [1]. Not only is there a lack of research in this field, but also the quality of the available literature is disturbing. Most of the evaluation methods currently used in undergraduate CPT education rely too heavily on ‘soft’ endpoints, such as satisfaction with the education received, and on intermediate endpoints, such as increase in knowledge and skills instead of improvement of patient care. Moreover, measures of knowledge and skills are often not valid, because selfassessment does not reflect actual knowledge and skills. Both issues are discussed in this letter. First, the lack of ‘hard endpoints’ is a problem. In educational research, it is common to classify endpoints on the basis of the four levels of evaluation described in Kirkpatrick’s model of impact of education (modified by Freeth) [2, 3] (Table 1). Unfortunately, studies of CPT education with hard endpoints (levels 3 & 4) are rare. For example, in four systematic reviews of undergraduate CPT education [4–7], only 2 of the 63 included articles (3%) used level 3 or 4 endpoints to evaluate their educational interventions (Table 1). In fact, most of the included articles (47; 75%) used level 2 endpoints, so-called intermediate endpoints. Improvement in intermediate endpoints (Kirkpatrick level 2) does not necessarily translate into improvement in patient care (Kirkpatrick level 4). Thus it is difficult to interpret the results of level 2 studies in terms of their value for CPT education. Secondly, the validity of the (soft) endpoints used in educational research is sometimes dubious. A recent study showed that self-reported confidence in prescribing skills is poorly correlated with assessed competence [8]. A logical consequence of this finding is that self-reported confidence should not be used as the primary measure of students’ prescribing skills at the undergraduate level. This prompted us to question whether the same is true for pharmacology and

Structure, importance and recording of therapeutic information in the medical record: a multicentre observational study.

RATIONALE, AIMS AND OBJECTIVES Structuring the diagnostic section of the medical record (MR) improves diagnosis and communication between doctors. However, little is known about the therapeutic section of the MR. The aim of this study was to gain insight into the extent to which MRs are structured for therapeutic information, to determine which therapeutic data registrars and clinical consultants consider should be recorded in the MR and to what extent registrars record this information themselves. METHODS A multicentre observational study was carried out in the internal medicine outpatient clinics of five teaching hospitals in the Netherlands. Preformatted structure, importance and actual recording of therapeutic information was compared with a reference list of 35 therapeutic items based on the WHO Guide to Good Prescribing (e.g. drug name, indication for drug). RESULTS The preformatted structure of four paper MRs and one electronic MR was assessed. Eight of the 35 therapeutic items were listed in the paper MRs and 18 items in the electronic MR. Registrars and consultants agreed on the importance of recording most of the therapeutic items in the MR, 25 and 27 out of the 35 items, respectively; however, registrars recorded only 11 of the 35 items in the paper MR and 20 of the 35 items in the electronic MR. CONCLUSIONS The structure and content of paper and electronic MRs are not adequate. While both registrars and consultants agree on the importance of recording therapeutic items in the MR, registrars fail to record most of this information in practice. The results of this study can be used as starting point for the discussion regarding the necessity of structured recording of therapeutic information in the MR and its possible benefits with regard to medication safety and training of the new generation of prescribers.