|Year : 2013 | Volume
| Issue : 1 | Page : 4-8
Rational pharmacotherapy training for fourth-year medical students
Ayse Gelal, Mukaddes Gumustekin, M Aylin Arici, Sedef Gidener
Department of Pharmacology, Dokuz Eylul University, School of Medicine, Izmir, Turkey
|Date of Submission||19-Jun-2012|
|Date of Decision||18-Sep-2012|
|Date of Acceptance||29-Oct-2012|
|Date of Web Publication||24-Jan-2013|
Department of Pharmacology, Dokuz Eylul University, School of Medicine, Izmir
Source of Support: None, Conflict of Interest: None
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.
Keywords: Education, medical students, rational prescribing skills, rational pharmacotherapy, video footages
|How to cite this article:|
Gelal A, Gumustekin M, Arici M A, Gidener S. Rational pharmacotherapy training for fourth-year medical students. Indian J Pharmacol 2013;45:4-8
|How to cite this URL:|
Gelal A, Gumustekin M, Arici M A, Gidener S. Rational pharmacotherapy training for fourth-year medical students. Indian J Pharmacol [serial online] 2013 [cited 2021 Oct 22];45:4-8. Available from: https://www.ijp-online.com/text.asp?2013/45/1/4/106426
| » Introduction|| |
According to World Health Organisation (WHO) definition, rational pharmacotherapy (RPT) requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community. , A multitude of factors have been found to lead to irrational use of drugs and these affect at various levels at which drugs are handled.  Inadequate information and training of health workers are indeed major factors of irrational drug use in hospitals. , Drug prescription is difficult and requires a thorough knowledge of the disease and the pharmacological properties of the drugs. It has been widely accepted that general practitioners' prescribing habits are not easily altered once established. Thus, good prescription training and also practical applications should be given during undergraduate education to prevent bad prescribing habits. Different educational approaches have been developed so far for that purpose. Several studies have shown that WHO/ Good Prescribing Model have a good impact on RPT education. ,,,
In academic year 2008/9, Dokuz Eylul University School of Medicine (DEUSM) decided to implement a new course programme on RPT for fourth-year medical students. Pharmacology lectures and learning objectives are given in 2 nd and 3 rd years of the education in DEUSM. 4 th and 5 th years are task based learning years. Applying knowledge of pharmacology to therapeutics was the main purpose of the integration of the course into the curriculum. Problem-based learning (PBL) teaching style was used in the course programme that was designed based on the WHO/Good Prescribing Model. , We thought that this model would be successful since we have been using PBL education system in DEUSM since 1997/8. Indeed, we reported that the fourth-year medical students in 2008/9 and 2009/10 academic years markedly benefited from the RPT course in developing rational prescribing skills. 
In academic year 2010/11, we implemented two video footages to the RPT course programme. We hypothesized that WHO/ Good Prescribing method combined with video assisted education would be more effective than WHO/Good Prescribing method alone to improve students' skills. The video footages involved doctor-patient conversation in treatment planning and prescription. In one of the videos, the doctor obeyed the RPT rules strictly, while in the other video the doctor disobeyed major RPT rules. The students were asked to evaluate the doctors' behaviour and score the appropriateness of their attitudes to RPT criteria using a checklist. Then, group discussion was done, and all the evaluated criteria were discussed separately by the tutor.
In this study we aimed to evaluate the impact of RPT course program, reinforced by video footages, on problem solving and communication skills of the students.
| » Materials and Methods|| |
Participants and RPT Course Programme
The 5-day RPT course programme was integrated to the curriculum at the beginning of fourth- academic year. These students had almost completed basic pharmacology curriculum during the first three years and were about to start the clinical task-based learning. The number of students was 155 in 2010/11 academic years. Objective structured clinical examination (OSCE) was done before (pre-test) and after (post-test) the course. The results of the students, who had taken both tests, were included in the study (n =147). Results were compared with the results of our previous study;  which showed the impact of RPT course programme to students' rational pharmacotherapy skills. The number of students in the previous study who had taken both tests was 131. The students in both studies had undergone the same RPT education other than the addition of video footages in the new study. The education was given by the pharmacologists working as a staff member in DEUSM.
The students in both years were divided into 10-11 groups; each consisting of 12-15 students. Each group discussed the same clinical scenarios. Urinary tract infection (UTI) was discussed during 1 st and 2 nd days of the course. Patient diagnosed with uncomplicated UTI was the 1 st case. Students had to select the best drug "(p)ersonal-drug" and write a rational prescription  : Students chose the effective drug group according to four criteria: Efficacy, safety, suitability and cost. Next step was selecting a "(p)-drug" on the basis of four criteria mentioned above and writing a correct prescription. Then, the student was expected to explain the disease and therapeutic objectives to the patient, give him instructions on how to use the drug, warn him of the possible adverse effects and tell him to come back to monitor treatment. After the simple case scenario was discussed, the modified/complex clinical scenarios or simulated patients for special teaching points in drug choice were used.
Hypertension (HT) was discussed during 3 rd days and morning session of 4 th days of the course. On day 5, OSCE (post-test) was performed and feedback was collected.
There were six classroom lectures (45 minutes each) for all of the students during the course. Topics of the lectures were 'principles of RPT, Multi-Attribute Utility Analysis, P(ersonal) drugs'; 'prescription writing rules'; 'principles of pharmacokinetics and pharmacodynamics in pediatric, geriatric and obstetric patients'; 'principles of pharmacoeconomics'; 'drug-drug interactions'; 'generics, bioavailability and bioequivalence'.
Intervention to the Course Programme
In academic year 2010/11, on 4 th day afternoon of the course (it was independent learning hours during previous years) to further improve RPT decision-making competency of the students, we added two doctor-patient communication video footage each lasting 8 to 10 minutes to the RPT course programme. One of the videos showed how a well-trained doctor should prescribe rationally, whereas the other video showed a doctor disobeying major RPT rules. The students were asked to evaluate the doctors' behaviour and score the appropriateness of their attitudes to RPT criteria using a checklist. Then, group discussion was done, and all the evaluated criteria were discussed separately by the tutor. This was also a small-group, face-to-face education session. One session, consisting of watching of two videos, scoring and small group discussion lasted 60 minutes.
Students were assessed by pre/post-tests using OSCE. OSCE scoring sheets were prepared for UTI and HT. Simulated patients diagnosed with UTI and HT were used for pre-test and post-test, respectively. Before the start of an OSCE, the written diagnosis of the patient was given to the student. The student had to choose and prescribe the "(p)-drug" treatment interactively with the simulated patient and had to substantiate the chosen therapy. Also the students were expected to give the information to the patients about the objectives and the plan of the treatment, effects, unwanted effects, drug interactions, use instructions, and warnings for the prescribed drug(s), and how to monitor the outcome of the treatment, etc. The total OSCE score was 100 and divided as 80 points for problem solving skills and 20 points for communication skills:
Problem solving skills were evaluated mainly at six steps which consist of a number of sub steps:
Communication skills were evaluated at 4 steps:
- definition of the disease,
- determination of treatment aims,
- determination of non-pharmacological treatment,
- selection of the personal drug (P-drug) and treatment options, evaluation of drug eligibility for patient,
- prescribing (presence of date, name-surname, diploma number, address and signature of the physician, name, age, sex, address, protocol number and diagnosis of the patient), content (generic or trade name, dosage, dosage form, strength and total amount of the drug, use instructions, and warnings, if there should be any), symbol Rx, S and readable handwriting.
- informing the patient about drug adequately (if drug therapy was explained correctly including effects, side effects, dosage, use instructions, warnings, and monitoring the therapeutic outcome) and next appointment.
The student score was calculated as follows: Student's score for each step was divided by step's maximum score and multiplied by 100.
- talk to patients clearly,
- allow adequate time to patients to express themselves,
- ask the patients if they understood the given information,
- ask patients to repeat the prescription.
All data were expressed as mean ± SEM. Statistical analysis of data was evaluated by unpaired Student's t-test for 2009/10 and 2010/11 academic years' OSCE results comparison and by paired Student's t-test for pre-test and post-test OSCE results comparison (GraphPad Instat™, 1990-1994, GraphPad Software V2.05a 9342, USA). p value less than 0.05 was considered significant.
| » Results|| |
OSCE scores (six steps of problem solving skills and communication skills) were statistically higher after the education in 2010/11 academic year [Figure 1].
The 2010/11 academic year group's total post-test OSCE score was significantly higher than 2009/10 academic year's results (76.0 vs 73.2%, p = 0.0246).
The 2010/11 academic year group performed significantly better than the 2009/10 academic year group on four steps: The scores on step 1, "define the patient's problem," increased significantly (p < 0.001) from 62.5±2.7% to 83.2%. The scores on step 2, "specify the therapeutic objective," increased (p < 0.001), from 56.2 to 72.5%. The scores on step 3, "specify the non-pharmacological treatment," increased significantly (p < 0.001), from 58.7 to 71.9%. The scores on step 4, "choose a (drug) treatment, taking all relevant patient characteristics into account," increased significantly (p = 0.0216), from 69.7 to 74.8%. No significant differences were found between the groups on the scores on step 5, "write a prescription". The scores on step 6, "give patient information, taking all relevant drug use and adverse effects and monitorization," increased, but it was not significant (58.9 vs 63.0%, p = 0.08) [Figure 2].
Evaluated communication skills ("talk to patients clearly", "allow adequate time to patients to express themselves", "ask the patients if they understood the given information" and "ask patients to repeat the prescription") post-test scores were not statistically different between the groups.
|Figure 1: Problem solving score on the six steps of the World Health Organization (WHO) six-step plan for the 2010/11 academic year (n = 147). Data are presented as mean percentage of the maximum with error bars. P< 0.05 was considered signifi cant. □ pre-test results; ■ post-test results|
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|Figure 2: (a) Problem solving pre-test OSCE score on the six steps of the World Health Organization (WHO) six-step plan for the 2009/10 (n = 131) and 2010/11 (n = 147) academic year. Data are presented as mean percentage of the maximum with error bars. P < 0.05 was considered signifi cant. □ 2009/10 academic year; ■ 2010/11 academic year (b) Problem solving post-test OSCE score on the six steps of the World Health Organization (WHO) six-step plan for the 2009/10 (n = 131) and 2010/11 (n = 147) academic year. Data are presented as mean percentage of the maximum with error bars. P < 0.05 was considered signifi cant. #160; 2009/10 academic year; ■ 2010/11 academic year|
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| » Discussion|| |
This study showed that the added structured video footages to WHO/Good Prescribing Model in RPT education improved the level of rational pharmacotherapy by medical students. As part of this education, students were taught how to select, prescribe, and evaluate a drug regimen rationally. In our previous study, we had reported that fourth year medical students had markedly benefited from the course in developing their RPT knowledge and skills.  In this study, what was different from the previous one was the addition of video footages. The video footages involved doctor-patient conversation in treatment planning and prescription. One of the videos showed how a well-trained doctor should prescribe rationally, whereas the other video showed a doctor disobeying major RPT rules. The students were asked to evaluate the doctors' behaviour and score the appropriateness of their attitudes to RPT criteria using a checklist. Then, group discussion was done, and all the evaluated criteria were discussed separately by the tutor.
Even if correct drug is prescribed, patients may not adhere to prescription due to lack of communication between doctors and patients.  Communication between patient and doctor is one of the main steps of RPT education. The patients should be informed in detail by the doctors regarding their illness, why this treatment is required, how they will use the drugs and when their next appointment will be. In our study, video assisted RPT education followed by group discussions considerably improved the skills of the students to inform their patients about their diseases and the aims of treatment, when compared to the previous year's study in which RPT course programme without the addition of video footages was applied.
The implementation of video footages further enhanced the attitudes of the students significantly for informing patients about non-pharmacological treatment, choosing p(ersonal) drug treatment, taking all relevant patient characteristics into account. The attitudes for giving information to the patient (regarding the use of drugs, adverse effects and monitorization) increased after video implementation when compared to non-video assisted RPT, but it was not statistically significant (58.9 vs 63.0%). It is clear that this score is not satisfactory and needs to be further improved.
The irrational prescribing of drugs is a common problem that may lead to medication errors. It is well known that many medication errors are made by young doctors. ,,,, In order to improve rational prescribing, the authorities in many countries are putting a lot of effort to the teaching of pharmacotherapy. ,,[ 18] It is not clear if education alone can reduce prescribing errors. Although a number of recommendations for undergraduate prescribing education have been published, there are no clear guides on how these competencies should be achieved. ,, One of the recent comprehensive systematic reviews written by Ross et al. investigated the extent to which educational interventions can improve students' prescribing skills. They could not find clear evidence on how the future of prescribing education should be. However, they suggested that the WHO Good Prescribing Guide, which was also used in our study, was the most widely used educational development for improving prescribing.
In a study done by Ruskamp and Denig different educational approaches to improve rational prescribing were discussed. In their study, they showed that face-to-face education and the use of feedback combined with discussion in a peer group was the most effective way of improving prescribing skills. Feedback without any recommendation or discussion with prescriber as well as the use of printed material did not seem to be helpful. , On the other hand, some recently published studies have shown that the video feedback method was effective for improving doctors' key interaction skills. ,, Our findings confirmed the usefulness of both approaches, e.g. video feedback method and face-to-face education by means of group discussions, in improving rational prescribing skills of doctors.
Strengths and Limitations of the Study
This study is a 'before and after study' that met relevant quality criteria. Both the pre and post measures were assessed in the same way.
Our study has some limitations as most of the other similar studies. The assessment was conducted in controlled conditions with simulated patients. Also, the assessment was done with only one scenario in which the students had been trained during the pharmacotherapy program.
The results also reflect the short term effects of education. We do not know if the observed improvements in safe prescribing will be maintained.
| » Conclusion|| |
Implementation of video footages and group discussions to WHO/Good Prescribing method seems to be helpful in improving the rational prescribing skills of medical students.
| » Acknowledgements|| |
This study was presented by AG as a poster in 10 th Congress of the European Association for Clinical Pharmacology and Therapeutics in Budapest, 26-29 June, 2011.
| » References|| |
|1.||le Grand A, Hogerzeil HV, Haaijer-Ruskamp FM. Intervention research in rational use of drugs: A review. Health Policy Plan 1999;14:89-102. |
|2.||Oshikoya KA, Oreagba I, Adeyemi O. Sources of drug information and their influence on the prescribing behaviour of doctors in a teaching hospital in Ibadan, Nigeria. Pan Afr Med J 2011;9:13. |
|3.||Kutyabami P. "Rational Drug Use" as a Public Health Concept (In developing world). Available from: http://www.cwru.edu/med/epidbio/mphp439/Rational%20Drug%20Use.htm [Last cited on 2012 June 18]. |
|4.||Maxwell SR, Cascorbi I, Orme M, Webb DJ. Joint BPS/EACPT Working Group on Safe Prescribing. Educating European (junior) doctors for safe prescribing. Basic Clin Pharmacol Toxicol 2007;101:395-400. |
|5.||De Vries TP, Henning RH, Hogerzeil HV, Bapna JS, Bero L, Kafle KK, et al: Impact of a short course in pharmacotherapy for undergraduate medical students: An international randomized controlled study. Lancet 1995;346:1454-7. |
|6.||Akici A, Kalaca S, Goren MZ, Akkan AG, Karaalp A, Demir D, et al. Comparison of rational pharmacotherapy decision-making competence of general practitioners with intern doctors. Eur J Clin Pharmacol 2004;60:75-82. |
|7.||Akici A, Goren MZ, Aypak C, Terzioglu B, Oktay S. Prescription audit adjunct to rational pharmacotherapy education improves prescribing skills of medical students. Eur J Clin Pharmacol 2005;61:643-50. |
|8.||Guney Z, Uluoglu C, Yucel B, Coskun O. The impact of rational pharmacotherapy training reinforced via prescription audit on the prescribing skills of fifth-year medical students. Int J Clin Pharmacol Ther 2009;47:671-8. |
|9.||De Vries TP, Henning RH, Hogerzeil HV, Fresle DA. Guide to good prescribing. WHO Action programme on essential drugs. Geneva: World Health Organization; 1994. |
|10.||Hocaoglu N, Guven H, Gidener S, Tuncok Y, Kalkan S, Gumustekin M, et al. Short term impacts of rational pharmacotherapy course on the rational prescribing skills of fourth-year students of Dokuz Eylul University Medical Faculty. DEÜ Týp Fakültesi Dergisi 2011;25:15-24. |
|11.||Scobie SD, Lawson M, Cavell G, Taylor K, Jackson SH, Roberts TE. Prescribing and administering medicines safely: Teaching and assessment. Med Educ 2003;5:434-7. |
|12.||Sandilands EA, Reid K, Shaw L, Bateman DN, Webb DJ, Dhaun N, et al. Impact of a focussed teaching programme on practical prescribing skills among final year medical students. Br J Clin Pharmacol 2011;71:29-33. |
|13.||Heaton A, Webb DJ, Maxwell SR. Undergraduate preparation for prescribing: The views of 2413 UK medical students and recent graduates. Br J Clin Pharm 2008;66:128-134. |
|14.||Rothwell C, Burford B, Morrison J, Morrow G, Allen M, Davies C, et al. Junior doctors prescribing: Enhancing their learning in practice. Br J Clin Pharmacol 2012;73:194-202. |
|15.||Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: Their incidence and clinical signiﬁcance. Qual Saf Health Care 2002;11:340-4. |
|16.||Palcevski VV, Vitezic D, Zupan G, Simonie A. Education in clinical pharmacology at the Rijeka School of Medicine, Croatia. Eur J Clin Pharmacol 1998;54:685-9. |
|17.||Richir MC, Tichelaar J, Stanm F, Thijs A, Danner SA, Schneider AJ, et al. A context-learning pharmacotherapy program for preclinical medical students leads to more rational drug prescribing during their clinical clerkship in internal medicine. Clin Pharmacol Ther 2008;4:513-6. |
|18.||Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: A prospective study. Lancet 2002;20:1373-8. |
|19.||Likic R, Maxwell SR. Prevention of medication errors: Teaching and training. Br J Clin Pharmacol 2009;67:656-61. |
|20.||Ross S, Loke YK. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 2009;67:662-70. |
|21.||Ruskamp FM, Denig P. Impact of feedback and peer review on prescribing: Occas Pap R Coll Gen Pract 1995;69:13-9. |
|22.||Ross S, Bond C, Rothnie H, Thomas S, Macleod MJ. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol 2009;67:629-40. |
|23.||Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. Med J Aust 2008;188:89-94. |
|24.||Fukkink RG, Trienekens N, Krame LJ. Video feedback in education and training: Putting learning in the picture. Educ Psychol Rev 2011;23:45-63. |
|25.||Nilsen S, Baerhei A. Feedback on video recorded consultations in medical teaching: Why students loathe and love it - a focus-group based qualitative study. BMC Med Educ 2005;5:28. |
[Figure 1], [Figure 2]