1. Giving priority to problems/diseases

Rather than just focussing on the features of a particular drug or treatment, bulletins can present the available evidence on the drug in the context of the epidemiological background and the reality of medical practice. They can discuss the practicality of the treatment in real life, and offer practical suggestions on managing the disease. Being independent, they can discuss and compare the different treatments available for managing the disease.

2. Dealing with uncertainty

Prescribers face problems, for example, when treating patients (and populations) whose characteristics do not match those of the published knowledge base (e.g. the trial participants may have been males aged 25 - 45). In these circumstances, slavishly adhering to the published data would not be consistent with the principles of rational use of medicines. Bulletins can help clinicians deal with this difficulty because they can present and discuss problems of uncertainty. The text must make clear which statements are evidence-based and which have weaker support. The section of an article dealing with uncertainty may well need to be longer than that devoted to discussing evidence. The text should offer clear recommendations, and these need to be based on an intelligent search for a rational approach. The reasons for uncertainty, and the need to discuss it with prescribers, are likely to differ from country to country. For example, it might be useful to recommend strategies for management when diagnostic resources are scarce.

3. Encouraging and facilitating audit and monitoring

There are often gaps between the principles of rational use of medicines and what happens in practice. Bulletins should recognise these gaps and suggest practical remedies in a positive way. For example, advice may include suggestions on methods for monitoring the problem and then auditing practice later in order to see if practice or outcomes have improved. The focus should be on offering explanations and suggesting possible solutions. It will help readers' perception of bulletins if editors can be seen as people who can, and wish to, help resolve issues at a practical level, rather than just being seen as having expertise only on principles. In addition, readers should be told when data from well-controlled trials are needed and what questions these should address. By identifying what is not known bulletins can encourage and facilitate research, monitoring and audit.

4. Communicating with patients and the public

In areas where the gap between evidence and actual practice threatens the principles of rational drug use, it is important to help prescribers enter into a dialogue and alliance with patients (and also more broadly with the public). Even if a bulletin is aimed at health professionals, to give them technical information, it needs to give space to non-drug centred discussion, addressing the cultural determinants of drug use (perceptions, acceptability, expectations). Using published evidence whenever possible, the challenge is to address the 'everyday' issues of management, offering solutions where possible. For example, bulletins can deal with the problems parents face when dealing with minor symptoms in their children, the handling of forgetfulness or dementia in the elderly, the integration of medicines with traditional or complementary strategies, and can offer advice on helpful non-drug measures for managing conditions.

Bulletins directed expressly at a lay (non-healthcare) audience include Worst Pills, Best Pills (USA) [http://www.citizen.org/hrg/] and Kusuri-no-Check (Japan) [http://npojip.org]. In other arrangements 'lay' bulletins are published as 'sister' pamphlets based on a 'healthcare' bulletin but 'translated' for a lay readership; an example of this is Drug and Therapeutics Bulletin's Treatment Notes (UK) [http://www.dtb.org.uk/dtb/tnotes/]. Other bulletins produce press releases about the topics of each issue which might be of interest to the public, and allow the lay press to reproduce them (e.g. la revue Prescrire: its press releases are disseminated in different francophone countries, and this create links with lay-press journalists).

The growing literature on the more patient-orientated issues is one with which bulletin editors need to become familiar. To do this they may need the help of people outside the core editorial staff. Often the task is to translate successful approaches across cultural and socioeconomic settings.