Putting good prescribing theory into practice

Editor,

It is widely accepted that most recent medical graduates do not prescribe optimally, even though they are adequately or even well informed about drugs. This is because pharmacology teaching is usually drug oriented, with clinical training often focusing on diagnostic skills or management. Consequently prescribing skills remain weak, and bad prescribing habits lead to ineffective treatment.

In its very useful training manual, Guide to Good Prescribing¹, WHO suggests guidelines for training undergraduates to improve their prescribing skills. Particular emphasis is given to: defining the patient’s problem; specifying therapeutic objectives; verifying the suitability of the P (Personal) drug chosen by the prescriber; writing a prescription; giving information, instructions and warnings to patients; and monitoring and stopping treatment.

¹de Vries TPGM, Henning RH, Hogerzeil HV, Fresle DA. Guide to good prescribing. Geneva: World Health Organization; 1994.

In our medical college, pharmacology teaching traditionally consisted of drug/disease oriented lectures, pharmaco-dynamic experiments on isolated tissues and laboratory animals, and pharmacy experiments. However, based on the advice in Guide to Good Prescribing we have improved our pharmacology curriculum.

Our course begins with an introductory lecture to all students, which covers the importance of good prescribing, looks in detail at the different sections of a prescription and examines common errors.

Next, about 25 common clinical problems are discussed on different occasions by groups of 20-30 students. A tutor (a medical graduate with experience in clinical medicine, and preferably a postgraduate qualification in pharmacology) introduces a problem. The students divide into sub-groups of 4-6, with each group formulating its own diagnosis and therapeutic objectives, selecting the P-drug/s and writing the prescription and instructions for the patient. Group leaders present their findings at a plenary session. The tutor suggests improvements and comes up with a final prescription, which is noted by the students. Similarly, at another group session, the inventory of P-drugs is discussed in groups.

We decided to compare the prescribing skills of our medical students in examinations in 1995, with those taking exams in 1996 and 1997. We looked at: understanding of patient’s problem/diagnosis; drug selection; prescription writing; instructions to patients and overall grading. In all cases a significant improvement was recorded. For example, in terms of understanding the patient’s problem, marks rose from 47% in 1995 to 73.5% in 1997 and overall gradings went from 28.2% in 1995 to 61.1% in 1997. For us these results confirm the benefits of modifying the pharmacology curriculum in line with the recommendations of Guide to Good Prescribing.

- M.A. Randhawa, A.A. Tanwir, A. Zia, A. Azeem, A. Munir, Department of Pharmacology and Therapeutics, Rawalpindi Medical College, Rawalpindi, Pakistan, Malik SZL, Department of Biochemistry, Rawalpindi Medical College, Rawalpindi, Pakistan, Malik SA., Department of Biological Sciences, Quaid-e-Azam University, Islamabad, Pakistan.