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How prepared are medical graduates to begin prescribing?

As almost all inpatients and about half of all general practice consultations require a prescription, it is essential that drugs are prescribed effectively, safely and on the basis of an understanding of the principles of pharmacology and therapeutics. In the past, prescribing has been perceived as a skill that could be acquired on the job, as have managing workload, being on call and performing clinical procedures. However, most medical graduates are under-prepared for prescribing, both in terms of the underpinning pharmacological knowledge, and the practical elements, such as calculating dosages, or writing up an inpatient medication chart or discharge script. New graduates are required to prescribe many times each day in the medication chart, which often includes initiation of high-risk therapies, such as anticoagulation, insulin and opioid analgesics. Demands have increased because of an increased number of drugs per patient, higher patient throughput, older patients with more co-morbidities and more complicated regimens. Prescribing errors are common and are more likely to occur in the first year after graduation than in all other years. A recent symposium emphasized the importance of education as the cornerstone in improving prescribing and recommended enhanced pharmacology and therapeutics training for medical students. Prescribing is a core skill which should be taught to every medical student and their competency assessed before they are allowed to prescribe to sick patients from day one of their internship. It is no longer acceptable to assume interns will pick up these skills as they go, or that it is safe because they are supervised in a teaching hospital. In reality, scripts are seldom checked by their medical superiors. In studies of prescribing errors in hospital, inadequate supervision is an important factor, yet students expect to be given instructions and to be contacted if they make mistakes. The novice’s lack of understanding of the complexities of prescribing does not appear to be appreciated or addressed by supervisors. An exception is where interns work in hospitals with a ward pharmacist service. By checking medication charts, experienced clinical pharmacists can play a key role in the defences against prescribing error. Unfortunately, not all interns work in clinical areas with such a pharmacist and where they do, pharmacists are not available all of the time. With the international move to changes in curriculum design away from didactic learning and towards an integrated problem-based approach, some of the more traditional learning of pharmacology has been lost with nothing to replace it. Studies in recent medical graduates and interns both in Australia and abroad have identified that undergraduate training in clinical pharmacology and therapeutics is insufficient to prescribe safely and rationally, and prescribing is one of the most frequently identified medical school learning needs. The article by Hilmer et al. in this issue of the Journal, based on a cross-sectional study conducted at four New South Whales hospitals in January 2008, provides further evidence that medical graduates are not adequately prepared for safe and effective prescribing. While the primary finding was of significant deficits in prescribing, graduates indicated that they would have liked more clinical pharmacology training at medical school. Most did not feel their pharmacology training was equivalent to training in other medical disciplines and the area they felt least prepared for was prescribing. It would have been useful to have had a second assessment after orientation. However, while intern orientation week provides an invaluable opportunity to start getting graduates up to speed for medical practice, it is too late to start learning the complexities of prescribing. This must be adequately covered during their undergraduate training, with the few extra hours during orientation acting as revision/re-enforcement. It would also have been interesting to compare the performance of those who had previously worked through the National Prescribing Service (NPS) modules, with those who had not. In 1997 the NPS was created to implement the national Quality Use of Medicines programme, the fourth arm of the Australian National Medicine’s Policy. One of the highest priorities identified in a nationwide survey to identify priority areas for the NPS was given to improving the quality of prescribing education. A web-based interactive programme comprising a set of modules was developed, with representation from all major medical schools Internal Medicine Journal 39 (2009) 425–427