|Guide to good prescribing: A practical manual (WHO/EDM, 1994, 115 p.)|
At the start of clinical training most medical students find that they don't have a very clear idea of how to prescribe a drug for their patients or what information they need to provide. This is usually because their earlier pharmacology training has concentrated more on theory than on practice. The material was probably 'drug-centred', and focused on indications and side effects of different drugs. But in clinical practice the reverse approach has to be taken, from the diagnosis to the drug. Moreover, patients vary in age, gender, size and sociocultural characteristics, all of which may affect treatment choices. Patients also have their own perception of appropriate treatment, and should be fully informed partners in therapy. All this is not always taught in medical schools, and the number of hours spent on therapeutics may be low compared to traditional pharmacology teaching.
Clinical training for undergraduate students often focuses on diagnostic rather than therapeutic skills. Sometimes students are only expected to copy the prescribing behaviour of their clinical teachers, or existing standard treatment guidelines, without explanation as to why certain treatments are chosen. Books may not be much help either. Pharmacology reference works and formularies are drug-centred, and although clinical textbooks and treatment guidelines are disease-centred and provide treatment recommendations, they rarely discuss why these therapies are chosen. Different sources may give contradictory advice.
The result of this approach to pharmacology teaching is that although pharmacological knowledge is acquired, practical prescribing skills remain weak. In one study, medical graduates chose an inappropriate or doubtful drug in about half of the cases, wrote one-third of prescriptions incorrectly, and in two-thirds of cases failed to give the patient important information. Some students may think that they will improve their prescribing skills after finishing medical school, but research shows that despite gains in general experience, prescribing skills do not improve much after graduation.
Bad prescribing habits lead to ineffective and unsafe treatment, exacerbation or prolongation of illness, distress and harm to the patient, and higher costs. They also make the prescriber vulnerable to influences which can cause irrational prescribing, such as patient pressure, bad example of colleagues and high-powered salesmanship. Later on, new graduates will copy them, completing the circle. Changing existing prescribing habits is very difficult. So good training is needed before poor habits get a chance to develop.
This book is primarily intended for undergraduate medical students who are about to enter the clinical phase of their studies. It provides step by step guidance to the process of rational prescribing, together with many illustrative examples. It teaches skills that are necessary throughout a clinical career. Postgraduate students and practising doctors may also find it a source of new ideas and perhaps an incentive for change.
Its contents are based on ten years of experience with pharmacotherapy courses for medical students in the Medical Faculty of the University of Groningen (Netherlands). The draft has been reviewed by a large body of international experts in pharmacotherapy teaching and has been further tested in medical schools in Australia, India, Indonesia, Nepal, Netherlands, Nigeria and the USA (see Box 1).
Box 1: Field test of the Guide to Good Prescribing in seven universities
The impact of a short interactive training course in pharmacotherapy, using the Guide to Good Prescribing, was measured in a controlled study with 219 undergraduate medical students in Groningen, Kathmandu, Lagos, Newcastle (Australia), New Delhi, San Francisco and Yogyakarta. The impact of the training course was measured by three tests, each containing open and structured questions on the drug treatment of pain, using patient examples. Tests were taken before the training, immediately after, and six months later.
After the course, students from the study group performed significantly better than controls in all patient problems presented (p<0.05). This applied to all old and new patient problems in the tests, and to all six steps of the problem solving routine. The students not only remembered how to solve a previously discussed patient problem (retention effect), but they could also apply this knowledge to other patient problems (transfer effect). At all seven universities both retention and transfer effects were maintained for at least six months after the training session.
This manual focuses on the process of prescribing. It gives you the tools to think for yourself and not blindly follow what other people think and do. It also enables you to understand why certain national or departmental standard treatment guidelines have been chosen, and teaches you how to make the best use of such guidelines. The manual can be used for self-study, following the systematic approach outlined below, or as part of a formal training course.
Part 1: The process of rational treatment
This overview takes you step by step from problem to solution. Rational treatment requires a logical approach and common sense. After reading this chapter you will know that prescribing a drug is part of a process that includes many other components, such as specifying your therapeutic objective, and informing the patient.
Part 2: Selecting your P-drugs
This section explains the principles of drug selection and how to use them in practice. It teaches you how to choose the drugs that you are going to prescribe regularly and with which you will become familiar, called P(ersonal)-drugs. In this selection process you will have to consult your pharmacology textbook, national formulary, and available national and international treatment guidelines. After you have worked your way through this section you will know how to select a drug for a particular disease or complaint.
Part 3: Treating your patients
This part of the book shows you how to treat a patient. Each step of the process is described in separate chapters. Practical examples illustrate how to select, prescribe and monitor the treatment, and how to communicate effectively with your patients. When you have gone through this material you are ready to put into practice what you have learned.
Part 4: Keeping up-to-date
To become a good doctor, and remain one, you also need to know how to acquire and deal with new information about drugs. This section describes the advantages and disadvantages of different sources of information.
The annexes contain a brief refresher course on the basic principles of pharmacology in daily practice, a list of essential references, a set of patient information sheets and a checklist for giving injections.
A word of warning
Even if you do not always agree with the treatment choices in some of the examples it is important to remember that prescribing should be part of a logical deductive process, based on comprehensive and objective information. It should not be a knee-jerk reflex, a recipe from a 'cook-book', or a response to commercial pressure.
In view of the importance that medical students be taught to use generic names, the International Nonproprietary Names (INNs) of drugs are used throughout the manual.
The WHO Action Programme on Essential Drugs would be very glad to receive comments on the text and examples in this manual, as well as reports on its use. Please write to: The Director, Action Programme on Essential Drugs, World Health Organization, 1211 Geneva 27, Switzerland. Fax 41-22-7914167.