Jelle Tichelaar

Teaching clinical pharmacology and therapeutics with an emphasis on the therapeutic reasoning of undergraduate medical students

BackgroundThe rational prescribing of drugs is an essential skill of medical doctors. Clinical pharmacologists play an important role in the development of these skills by teaching clinical pharmacology and therapeutics (CP&T) to undergraduate medical students. Although the approaches to teaching CP&T have undergone many changes over the last decennia, it is essential that the actual teaching of CP&T continues to be a major part of the undergraduate medical curriculum.ObjectivesThe learning objectives of CP&T teaching in terms of developing the therapeutic competencies of undergraduate medical students are described, with an emphasis on therapeutic decision-making. On the basis of current theories of cognitive psychology and medical education, context-learning is presented as an effective approach by which to achieve therapeutic competencies. An example of a CP&T curriculum is presented.

A Context‐Learning Pharmacotherapy Program for Preclinical Medical Students Leads to More Rational Drug Prescribing During Their Clinical Clerkship in Internal Medicine

The irrational prescribing of drugs seems to be a general problem in medical practice, occasionally leading to serious consequences. In order to improve the drug prescribing performance of medical students, a compulsory context‐learning pharmacotherapy module was implemented in 1998 in the medical curriculum of 2nd–4th‐year medical students at the VU University Medical Center (VUmc), Amsterdam, the Netherlands. As part of this program, preclinical medical students are taught how to select, prescribe, and evaluate a drug regimen rationally. The aim of this study was to investigate the effect of this preclinical pharmacotherapy program on the quality of rational prescribing during the ensuing clinical clerkship of these students in internal medicine. The results of this study indicate that preclinical context‐learning in pharmacotherapy leads to the use of more rational prescribing modalities by medical students during their ensuing clinical clerkship in internal medicine. This effect was obtained not only with respect to the clinical topics in which training had been given as part of the pharmacotherapy curriculum, but also for other disease situations that the students dealt with. This implies that students not only remember the specific information they have learned during the training, but are also able to apply the acquired skills in new situations (transfer effect).

Do medical students copy the drug treatment choices of their teachers or do they think for themselves

PurposeAlthough the importance of rational prescribing is generally accepted, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Because clinical teachers are an important role model for medical students, it is of interest to know whether this extends to therapeutic decision-making. The aim of this study was to find out which factors contribute to the drug choices made by medical students and their teachers (general practitioners and clinical specialists).MethodsFinal-year medical students (n = 32), and general practitioners (n = 29), lung specialists (n = 26), orthopaedic surgeons (n = 24), and internists (n = 24) serving as medical teachers from all eight medical schools in the Netherlands participated in the study. They were asked to prescribe treatment (drug or otherwise) for uncomplicated (A) and complicated (B) written patient cases and to indicate which factors influenced their choice of treatment, using a list of factors reported in the literature to influence drug prescribing.ResultsFinal-year medical students primarily based their drug choice on the factors ‘effectiveness of the drugs’ and ‘examples from medical teachers’. In contrast, clinical teachers primarily based their drug choice on the factors ‘clinical experience’, ‘effectiveness of the drugs’, ‘side effects of the drugs’, ‘standard treatment guidelines’, and ‘scientific literature’.ConclusionsMedical teachers would appear to base their drug choice mainly on clinical experience and drug-related factors, whereas final-year medical students base their drug choice mainly on examples provided by their medical teachers. It is essential that medical teachers clearly explain to their students how they arrive at a specific choice of medication since medical students tend to copy the therapeutic drug choices from their teachers, mainly because of a lack of experience. Presenting students with clinical therapeutic problems early during undergraduate training will not only give them a chance to gain experience in solving medical problems but will also give meaning to what they are studying as opposed to merely reproducing what they learn or copying what they are told.

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 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

PurposeThe 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.MethodsBetween 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).ResultsIn 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 recommendationsThe 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 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.

Pharmacovigilance Skills, Knowledge and Attitudes in our Future Doctors - A Nationwide Study in the Netherlands

Pharmacovigilance centres monitor the safety of drugs, based on adverse drug reactions (ADRs) reported by doctors, pharmacists and pharmaceutical companies. However, the under‐reporting of ADRs remains a major problem. Our aim was to investigate preparedness of future doctors for their role in pharmacovigilance, by assessing their pharmacovigilance awareness, skills and knowledge. The study was a nationwide e‐survey among medical students (third to sixth year) of all eight medical schools in the Netherlands. The survey consisted of questions regarding pharmacovigilance awareness, skills and knowledge. Overall, 874 students provided informed consent and participated (response 12%). Almost all students (96%) intended to report serious ADRs in their future practice. Almost half (44%) of the students did not know where to report an ADR, and 78% did not know which items were necessary for a good‐quality ADR report. While more than 78% of the students agreed that pharmacovigilance is an important topic in their medical education, only 26% found that their current curriculum covered pharmacovigilance adequately. Although ADR reporting is considered relevant and important among future doctors, many do not know where and what to report. This is highly undesirable and should have consequences for pharmacotherapy teaching.

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.