By Senthil Kumar Rajasekaran, David Nierenberg, Simon Maxwell, and Kelly Karpa
Prescribing is a fundamental part of the work of new residents, who write and review many prescriptions each day. It is a complex task requiring knowledge of medicines and the diseases they are used to treat, careful judgment of risks and benefits of treatment, and attention to detail. Lack of prescribing skills among residents is widely reported. It is also apparent in other research that this is an area the new residents find challenging. Granting these new doctors prescribing privileges without adequate training and assessment can encourage poor prescribing habits and promote medication errors.
Various studies estimate the total annual costs of preventable medication errors that can result in injury or death (“adverse drug events”) at between $17 and $30 billion. An Institute of Medicine report estimates mortality from preventable medication errors at 7,000 deaths each year. Notably, dosing errors make up 37 percent of all preventable medication errors and harmful drug interactions account for up to 11 percent of preventable medication errors. Inadequate knowledge and misapplication of knowledge regarding drug therapy seems to contribute to an astounding 30 percent of medication errors.
Another study found that about two-thirds of verified prescribing errors were made on the day of admission. Junior residents often coordinate early admission processes; these errors seem to indicate that they’re not ready to prescribe. Taken together, these figures highlight a crucial medical education gap around prescribing.
While the introduction of electronic prescribing in hospitals has led to prevention of some obvious errors, there is controversy about the extent to which these systems will prevent errors that actually lead to student harm. Pharmacists report prescribing errors that would never have occurred in hand-written medication orders. “Clicking” through a computerized system is itself causing errors.
Medical students must understand how to become safe and effective prescribers before they become physicians and gain the ability to prescribe independently. But in most medical schools, pharmacology training is limited to the basic science years, leaving medical graduates to acquire prescribing proficiency through clinical experience within their residency program. The task has become more challenging due to several trends: an expanding national formulary; more drugs per patient (polypharmacy); more patients; older, more vulnerable patients; more complicated therapeutic regimens; greater patient demand for information; and the increased threat of litigation.
The Medical Schools Council and the British Pharmacological Society are working jointly to develop and implement the Prescribing Skills Assessment (PSA). PSA was piloted in medical schools across the UK in 2012 and 2013. Between February and April 2013, the PSA pilot was delivered successfully to around 5,000 final year medical students in 29 out of 32 medical schools and received positive feedback. The assessment uses series of clinical vignettes to assess skills such as prescribing, prescription chart review, planning management, communicating important information to the patients, drug dosage calculation skills, adverse drug reactions, monitoring drug therapy, and data interpretation.
We have formed a consortium of like-minded medical school faculty members to address this key area in the United States. At Oakland University William Beaumont School of Medicine, we have designed a four-year longitudinal curriculum on prescribing competency, built into the Art & Practice of Medicine course. It includes a series of contact sessions, case discussions, and an assessment. Our long-term goal is to gain an eventual commitment from all U.S. medical schools to implement the standard assessment tool for their 3rd– and 4th-year medical students.
Senthil Kumar Rajasekaran is Director, Center for Excellence & Associate Professor at Oakland University William Beaumont School of Medicine.
David Nierenberg is Senior Advising Dean and the Chief of the Section of Clinical Pharmacology at the Geisel School of Medicine at Dartmouth.
Simon Maxwell is Professor of Student Learning/Clinical Pharmacology at the University of Edinburgh.
Kelly Karpa is an associate professor and Director of Medical Pharmacology Instruction at Penn State University College of Medicine, Hershey, PA.