<div>Title: Prescription Writing - Are We Training our Students Adequately?</div><div>Running title: Clinical Pharmacology and Prescription Writing</div><div>Authors:</div><ol><li>Arif Syed Faizullah Hashmi MD, Division of Clinical Pharmacology,
Dept. of Basic Medical Sciences, College of Medicine, Al Majmaah
University, Kingdom of Saudi Arabia</li><li>Rupinder Kaur Hashmi MD, Division of Clinical Pharmacology, Dept. of
Basic Medical Sciences, College of Medicine, Al Majmaah University,
Kingdom of Saudi Arabia</li><li>Talal Shakas Alghamdi MD, Dept. of Family Medicine, College of
Medicine, Al Majmaah University, Kingdom of Saudi Arabia</li></ol><div>Word Count: 1151</div><div>References: 5</div><div>Data sharing not applicable to this article as no datasets were
generated or analysed during the current study</div><div>WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?</div><div>Teaching of Clinical Pharmacology has been reduced in medical schools in
recent times and coupled with the demonstrated inadequate prescribing
skills amongst newly graduated doctors, poses an important problem with
implications for patient safety. Structured prescribing skills training
has been shown to work when used during medical school, and mostly forms
part of therapeutics teaching. Rarely have entire modules dedicated to
prescribing skills been used in medical schools and there was a need
felt to introduce and assess their effectiveness.</div><div>WHAT THIS STUDY ADDS?</div><div>Through this experiment in teaching prescribing skills, we have
demonstrated that a module dedicated to teaching Prescribing Skills,
based on a Clinical Pharmacology background, is both useful and
effective. There is a need to spread this idea of a dedicated
prescribing skill training framework to improve our current teaching
framework.</div><div>Abstract:</div><div>Teaching of Clinical Pharmacology has taken a backseat in most medical
schools worldwide, especially with the introduction of newer methods of
learning. Appropriate prescription writing skills depend on a large
measure on the understanding of Clinical Pharmacology and therapeutics.
The necessity of acquiring appropriate prescription writing skills, at
the same time coupled with a reduction in time allotted to the teaching
of Clinical Pharmacology poses unique problems. Through the introduction
of a special module geared towards teaching prescribing skills to
medical students, we have tried to mitigate the effects of reduction in
time allotted to Clinical Pharmacology teaching. Our experience in this
regard has been positive and we have found the module has served its
purpose well.</div><div>Prescription writing is the culmination of the process of medical
history taking, examination and diagnosis. Writing medical prescriptions
forms a substantial part of a Physician’s work. For the patient the
medical prescription reflects a chance of alleviating his suffering and
a hope for better health. Prescription writing on its own is a complex
process and is based on the fundamental understanding of Pharmacology
and Therapeutics(1,2). It may be said that prescription writing is both
an art and a science. Considering the amount of time Physicians spend in
writing prescriptions it would seem prudent that medical students would
be trained in the process of prescription writing. This would ensure
that students do not pick up a vital skill ‘on the job’ but learn it
through structured teaching. But the observation is that the teaching of
Clinical Pharmacology is on the decline in medical schools. This is a
global phenomenon and introduction of newer methods of medical teaching
like organ-based, problem-based learning systems seem to have
exacerbated this phenomenon(3). The lack of adequate instruction in
Clinical Pharmacology has been documented to have multiple adverse
effects on patient care. Prescribing errors are a leading cause of
preventable harm to the patients. Physicians, especially junior
physicians at the start of their medical careers have expressed
scepticism about their prescription writing skills. They tend to learn
prescription writing while ‘on the job’ and tend to imitate their
immediate supervisors, thus avoiding any independent thought about the
reasons behind drug selection and questions related to it(4).</div><div>The College of Medicine at Majmaah University follows a problem-based
learning curriculum for the teaching of medicine. There is no dedicated
time slot for teaching systemic pharmacology barring a short four-week
course on the principles of general pharmacology. The teaching of
Pharmacology is spread out over a four-year period, though the hours of
instruction are much less as compared to a traditional subject-based
medical curriculum. A felt need was expressed by the clinical faculty
for training students in prescribing skills. The oft received feedback
was that students were aware of the drugs and their uses but were unable
to describe their actual use in a clinical scenario. This seems like a
perplexing thing to say because students have spent four years reading
and learning about these drugs. On deeper probing what the Clinical
Teachers meant was the fact that students had no inkling about the
actual usage of the drugs but had only ‘theoretical’ knowledge about
their mechanisms of actions and other properties.</div><div>On questioning interns and students in the final year of medical school
we received a similar feedback. We had a cohort who had trained for four
years but was unsure how to do the ‘doctoring’ when it came to writing a
complete prescription. This was the genesis of the introduction of an
optional module in Clinical Pharmacology and Therapeutics. This is a
longitudinal module spread over 18 weeks involving 30 instruction hours
taught just before the start of the clinical instruction years. The
module is based on the 6-step method of the World Health Organization’s
guide to good prescribing (WHO-6-step), the only validated pharmacology
and pharmacotherapy education tool (5). The tool has been shown to be
effective in improving prescribing skills and help to develop the
learners thinking process. The tool insists on a step-wise application
of pharmacological knowledge ensuring development of a structured
thought process. It encourages application of basic principles
underlying behaviour of drugs in the body. Considering the increasing
number of drugs now available the possibilities of adverse and
unintended effects because of inappropriate drug use are increasing.
Simultaneously there has been a resurgence in use of herbal medicines
which tend to interact with many of the drugs prescribed by the
allopathic physician. The WHO-6-step tool ensures that learners consider
these possibilities when writing a prescription, thus eliminating some
of the most common causes of adverse effects. The optional nature of the
module provided us with an opportunity to examine two groups of students
with a similar level of background level of knowledge at the start. The
group of students who received instruction in Clinical Pharmacology
added to their baseline knowledge, while the students who did not opt
for this module continued to receive routine instruction in Pharmacology
as part of the medical curriculum. The module has been running
consecutively for four years now and we feel confident enough to comment
on its utility as an instruction tool. We polled instructors from the
clinical years about the utility of the module and an overwhelming
number responded positively mentioning significant differences between
students who opted for the module vis-à-vis students who continued with
only the routine instruction in Pharmacology. Some of the salient points
mentioned by multiple instructors included – demonstration of
structured prescription writing by students, extensive considerations
about potential causes of altered pharmacokinetics like age and
co-morbidity, use of calculator apps routinely for dose-calculation,
routine enquiring about use of alternative and herbal medicines, and a
consideration for deprescribing. These points are some of the most
important considerations when writing a prescription and the Clinical
Pharmacology &amp; Therapeutics module, using the WHO-6-step tool seems to
have helped the students to learn these skills. We are in agreement with
the clinical instructors that students have made an appreciable gain in
the prescription writing skills and are looking at the process
holistically. We also conducted a focussed group discussion with
students who have participated in this module. The student feedback
centred around the concepts of increased confidence in prescription
writing, integration of basic concepts in prescription writing,
informing the patients about drug effects and potential adverse effects,
using resources to find about drug dosages and effects. Overall there
was a sense of accomplishment and new skill acquisition amongst the
students.</div><div>Our intent with this communication is to raise the issue regarding the
relevance and importance of teaching Clinical Pharmacology and
Prescribing Skills to the undergraduate. It is our sincere hope that
this communication acts as a catalyst for formation of more concrete
guidelines in this regard in the undergraduate medical curriculum in
Saudi Arabia and elsewhere.</div><div>1. Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for
better prescribing. BMJ. 2006 Aug 31;333(7566):459–60.</div><div>2. Aronson JK. Rational prescribing, appropriate prescribing. Br J Clin
Pharmacol. 2004 Mar;57(3):229–30.</div><div>3. Wiernik PH, Public Policy Committee of the American College of
Clinical Pharmacology. A dangerous lack of pharmacology education in
medical and nursing schools: A policy statement from the American
College of Clinical Pharmacology. J Clin Pharmacol. 2015
Sep;55(9):953–4.</div><div>4. Keijsers CJPW, Segers WS, de Wildt DJ, Brouwers JRBJ, Keijsers L,
Jansen PAF. Implementation of the WHO-6-step method in the medical
curriculum to improve pharmacology knowledge and pharmacotherapy skills.
Br J Clin Pharmacol. 2015 Jun;79(6):896–906.</div><div>5. Guide to Good Prescribing - A Practical Manual: Part 1: Overview:
Chapter 1: The process of rational treatment: The process of rational
prescribing [Internet]. [cited 2019 Dec 29]. Available from:
https://apps.who.int/medicinedocs/en/d/Jwhozip23e/3.1.2.html</div>