Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009

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1 British Journal of Clinical Pharmacology DOI: /j x Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009 Lelia O Shaughnessy, 1,2 Inam Haq, 2 Simon Maxwell 3 & Martin Llewelyn 1,2 Correspondence Dr Martin J. Llewelyn PhD FRCP, Division of Medicine, Brighton and Sussex Medical School, Falmer, East Sussex BN1 9PS, UK. Tel.: Fax: m.j.llewelyn@bsms.ac.uk Keywords clinical pharmacology, therapeutics, undergraduate education Received 3 December 2009 Accepted 25 February Division of Medicine, 2 Medical Education Unit, Brighton and Sussex Medical School, Brighton, East Sussex and 3 Clinical Pharmacology Unit, University of Edinburgh Clinical Research Centre, Western General Hospital, Edinburgh, UK WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Junior doctors feel poorly prepared by their training in Clinical Pharmacology and Therapeutics and commonly make prescribing errors. Since 1993 the General Medical Council s guidance on undergraduate medical education Tomorrow s Doctors has emphasized the integration of Clinical Pharmacology and Therapeutics teaching within the medical curriculum. With the publication of a new version of Tomorrow s Doctors in 2009, medical schools will be further revising their Clinical Pharmacology and Therapeutics teaching. WHAT THIS STUDY ADDS Although we know what the recommendations for undergraduate teaching of Clinical Pharmacology and Therapeutics teaching are, there are no published data describing what is currently happening in UK medical schools. This paper describes the course structures, volume and range of teaching and assessment of Clinical Pharmacology and Therapeutics in the UK in Our data provide a foundation for schools looking to revise the Clinical Pharmacology and Therapeutics Teaching in the light of Tomorrow s Doctors AIM To describe the current structure, delivery and assessment of Clinical Pharmacology and Therapeutics (CPT) teaching in UK medical schools. METHODS An online questionnaire was distributed to the person with overall responsibility for CPT teaching at all UK medical schools in June RESULTS Thirty of the 32 UK medical schools responded. 60% of schools have a CPT course although in 72% this was an integrated vertical theme. At 70% of schools pharmacologists have overall responsibility for CPT teaching (clinical 67%, non-clinical 33%); at 20% teaching is run by a non-specialist clinician and at 7% by a pharmacist. Teaching is commonly delivered by NHS clinicians (87%) and clinical pharmacists (80%) using lectures (90%) but additionally 50% of schools use e-learning and 63% have a student formulary. CPT is assessed throughout the curriculum at many schools through written, practical examinations and course work. 90% of schools have specific CPT content in their written examinations. 90% of respondents believed that their students were fairly to well prepared for the foundation year but only 37% of schools gather data on the competence of their graduates. CONCLUSIONS CPT teaching in UK medical schools is very diverse. Most schools do not assess the performance of their graduates as prescribers and there is a lack of evidence that many of the teaching approaches employed are suitable for the development of prescribing skills. It is vital that developments in CPT teaching are driven by validated, real-world assessments of the prescribing skills of medical students and newly qualified doctors The Authors Journal compilation 2010 The British Pharmacological Society Br J Clin Pharmacol / 70:1 / / 143

2 L. O Shaughnessy et al. Introduction Newly qualified doctors are called upon to prescribe drugs many times every day. Their ability to do this safely and effectively has long been a cause of concern both in the UK and elsewhere [1, 2]. In 2001, an Audit Commission report concluded that undergraduate medical courses did not provide a thorough knowledge of safe medicines prescribing and administration [3]. In 2003 The General Medical Council (GMC) published guidance on the essential knowledge and skills that medical students must obtain by the time they graduate and the British Pharmacological Society (BPS) published a core curriculum for Clinical Pharmacology and Therapeutics (CPT) [4, 5]. Since the publication of the BPS curriculum, concern about the training of medical students in this area has continued and has been encapsulated most recently by Aronson et al. and Dornan et al. [6, 7]. In September 2009 the GMC published a revision of Tomorrow s Doctors which places considerably more emphasis on knowledge and competencies related to CPT [8]. Medical schools will now have to respond to these additional requirements. The aim of this study was to investigate how, and by whom, CPT is currently taught and assessed in UK medical schools and the extent of the variation in existing approaches. Methods A web-based questionnaire-based survey was ed to the heads of undergraduate education at the 32 UK medical schools. The questionnaire comprised 10 questions exploring the range of approaches currently being taken to the delivery and assessment of CPT teaching (Appendix 1). Results Thirty of the 32 (94%) UK medical schools responded to the survey. Course structure Eighteen schools (60%) had a dedicated CPT course and thirteen (72%) of these described an integrated vertical theme.three of these schools (17%) described their course as containing vertical and horizontal components while only one school described a completely horizontal CPT course. Eleven schools (37%) had no dedicated CPT course. One school did not state how the CPT course was structured. Staff responsible overall for teaching Respondents described themselves as pharmacologists in 21 medical schools (70%), two-thirds as clinical pharmacologists and one third as non-clinical. Clinicians who were not specialists in CPT and pharmacists were responsible for teaching in six (20%) and two (7%) of schools, respectively. In one school teaching responsibility was not given. Staff involved in teaching delivery Clinicians who were not specialist clinical pharmacologists (26/30 87%), clinical pharmacists (24/30 80%), clinical academics (23, 77%) and clinical pharmacologists (21/30 70%) are involved in teaching delivery. Biomedical scientists and members of the pharmaceutical industry were reported to contribute to teaching at 17 (57%) and five (17%) schools, respectively. Teaching methods employed and average number of hours devoted to each Respondents identified a variety of teaching methods employed (Figure 1A) and indicated the number of hours dedicated to each method (Figure 1B). Lectures were a common teaching modality and, on average, students received 33 h during their course. Self-directed learning was used at 23 schools (77%), clinically based learning at 21 schools (70%),small group work at 20 schools (67%) and problem-based learning (PBL) at 19 schools (63%). Student formulary Nineteen schools (63%) had developed a student formulary. This takes the form of a core drug list in 13/19 schools (68%), is compiled online at 6/19 (31%) and is part of a student portfolio at 3/19 (16%). At some of the medical schools where a formulary does not exist there are plans to develop one. Assessment methods The specific testing of CPT in written examinations was reported at 27 schools (90%) and these are usually in the latter years of the course (Figure 1C). Practical assessments such as OSCEs were reported at 22 schools (73%). Interprofessional education (IE) Only eight (27%) medical schools reported employing interprofessional education. Approaches included teaching with dental, nursing, pharmacy and pathology students. A small number of schools that do not employ IE reported either that there were difficulties in organizing it or that IE was being developed. Medical student transition to the foundation year Sixteen (53%) respondents described their students as being well and 11 (37%) as fairly well prepared for the transition from medical school to the foundation year. A minority described their students as not prepared. Reasons given for this were that the CPT course was in 144 / 70:1 / Br J Clin Pharmacol

3 Undergraduate pharmacology and therapeutics in the UK A % of medical schools B Number of hours C Number of schools Figure 1 Lecture Self-directed Clinical Problem based learning Lecture Clinical Problem based learning Small group work Small group work Online work Online work Seminars Prescribing workshops Seminars Prescribing workshops Year 1 Year 2 Year 3 Year 4 Year 5 Year of course Teaching and assessment of clinical pharmacology and therapeutics at United Kingdom Medical Schools. (A) The range of teaching methods employed, (B) the median number of hours devoted to different teaching methods (interquartile range and percentiles shown) and (C) assessment methods employed. Coursework (); Protfolio work ( ); Written ( ); OSCEs ( ) transition following integration, there was a need for more teaching and assessment of prescribing skills and the lack of a dedicated CPT exam. Follow-up of prescribing performance Two-thirds of schools do not gather information on the prescribing performance of their graduates in the foundation year. The 10 schools (33%) that gathered data did so by assessing confidence to prescribe, competence to manage patients on core drugs or indirectly through error reporting. Discussion Prescribing is a core skill of a newly qualified doctor but junior doctors are responsible for a large number of medication errors [7, 9]. Tomorrow s Doctors 2009 places major emphasis on CPT knowledge and competencies and this appropriately raises expectations but also poses a significant challenge for medical schools in an already demanding area of the curriculum. The structure and delivery of CPT teaching Despite concerns about the demise of CPT as a theme in the undergraduate medical curriculum a large number of UK medical schools claim to have a dedicated CPT course albeit one which is, in many cases, vertically integrated throughout the curriculum. Over a third of schools do not have a dedicated course although this might reflect the extent to which teaching has been integrated rather than any lack of CPT content. Teachers of CPT have diverse backgrounds both clinical and non clinical with or without specific pharmacology or pharmacy training. This variation in professional experience is valuable and the BPS itself has suggested that enthusiasm and expertise in the rational use of medicines is more important to success than professional background (2003 Curriculum paper). Pharmacists, in particular, offer important skills and experience that strengthen CPT teaching. Few schools currently undertake interprofessional learning activity although this might be an opportunity to foster good professional relationships in relation to prescribing. The role of the pharmaceutical industry in undergraduate medical education has recently been the matter of some debate [10 12]. Doctors need a good understanding of drug development, marketing and a sophisticated approach to interactions with the drug industry and company representatives. In schools where there are not specialist clinical pharmacology teams it is likely that this subject will have to be addressed by nonclinical pharmacology specialist clinicians and pharmacists. While improvements in the relationship between clinicians and the pharmaceutical industry generally may be sufficient motivation in itself for industry involvement, Br J Clin Pharmacol / 70:1 / 145

4 L. O Shaughnessy et al. schools adopting this approach must moderate and monitor this interaction very carefully. In line with BPS recommendations, many schools have developed student formularies. Our experience is that while a student formulary is useful for defining core knowledge for the therapeutics curriculum, it has to be supported by instruction in its practical application to safe prescribing. An important area for further research will be assessing the impact of these varied approaches to education, including e-learning, on achievement of the practical prescribing skills as assessed by a validated tool. Assessment of CPT Most schools continue to assess CPT in both written and practical examinations. We were surprised that 90% of respondents described specific assessment of CPT. It is possible that this relates to interpretation of our question to mean specific questions within wider-ranging examinations rather than specific examinations. One recommendation of Tomorrow s Doctors 2009, which we suspect many schools will find challenging, is the requirement in paragraph 117 that each outcome has to be assessed in a noncompensatable way. Many medical schools believe that their students are well prepared with respect to CPT for the transition from medical school to Foundation year but this is strikingly at odds with the views of the students and their employers [6]. This uncertainty might be resolved by developing validated assessments of prescribing skills relevant to foundation doctors in the workplace. Study limitations There are methodological limitations to our study. Our data are derived from a single individual at each school and may be biased either because the respondents have vested interests, or interpret the questions differently. Nevertheless, by getting responses from the person directly responsible for CPT training at the great majority of schools we have gained insight into the volume and scope of CPT teaching. Coinciding with the publication of Tomorrow s Doctors 2009 our data come at a time of renewed debate about the role of CPT in undergraduate medicine. Conclusion The new GMC recommendations relating to CPT are a challenge for medical schools and will require collaboration between clinicians, pharmacists, foundation schools and medical education departments to ensure that UK schools enable students to develop the appropriate skills to be effective prescribers. Competing interests There are no competing interests to declare. Appendix 1 BSMS Teaching of Clinical Pharmacology & Therapeutics at UK Medical Schools Survey Is there a dedicated Clinical Pharmacology and Therapeutics (CP&T) course in your undergraduate medical degree? How is the course structured? (More than one answer may apply) Yes Vertical theme Spiral theme No Horizontal theme Other If you do not have a dedicated CP&T course or you answer Other please give details on how CP&T teaching is delivered. 2. Who is responsible overall for Clinical Pharmacology and Therapeutics teaching in your undergraduate medical degree course? Post Title Professional Background Name* address* Telephone Number* *Provision of this information is optional 3. Who is involved in the delivery of Clinical Pharmacology and Therapeutics teaching in your undergraduate medical degree course? (More than one answer may apply) Clinical Academics Clinical Pharmacologists Clinical Pharmacists NHS clinicians Scientists Other If you answer Other please specify who is involved in teaching delivery. 4. What teaching methods are employed to deliver Clinical Pharmacology and Therapeutics teaching in your undergraduate medical degree course? (More than one answer may apply) Lectures Problem Based Learning Seminars Small group work Online work Prescribing workshops Clinical (e.g. ward rounds, clinics) Self-directed Other If you answer Other please specify the teaching method(s) employed. 146 / 70:1 / Br J Clin Pharmacol

5 Undergraduate pharmacology and therapeutics in the UK 5. Please estimate the number of CONTACT HOURS of Clinical Pharmacology and Therapeutics teaching that students receive dedicated to the following teaching methods: Lectures Problem Based Learning Seminars Small group work Online work Prescribing workshops Clinical (ward rounds,clinics) Other 6. Do you have a Student Formulary in your undergraduate medical degree course? final year medical students are for the transition from medical school to foundation year? Not prepared Fairly well prepared Well prepared Student preparation Extremely well prepared If you believe that your medical students are Not prepared or only Fairly well prepared please specify why. 10. Do you gather information on the prescribing performance of your graduates in their foundation year? Yes No Yes No If Yes what FORM does it take? (E.g. students compile as part of portfolio or are provided with a completed formulary. 7. How is student knowledge of Clinical Pharmacology and Therapeutics assessed in your undergraduate medical degree course? (More than one answer may apply) Year 1 Year 2 Year 3 Year 4 Year 5 Coursework Portfolio work Written exam OSCEs Student Formulary formative assessment Student Formulary summative assessment Other If Other please specify how knowledge in Clinical Pharmacology and Therapeutics is assessed. 8. Is Interprofessional Learning incorporated in the teaching of Clinical Pharmacology and Therapeutics in your undergraduate medical degree course? Yes No If Yes how is Interprofessional Learning employed? If No please specify why Interprofessional learning is not employed. 9. How well prepared with respect to Clinical Pharmacology and Therapeutics do you believe that your If you answer Yes what information do you gather? If No please specify why. REFERENCES 1 Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico F, Leape LL, Bates DW. Adverse drug events in ambulatory care. N Engl J Med 2003; 348: Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002; 11: The Audit Commission. A spoonful of sugar improving medicines management in hospitals. Audit Commission [Online] Available at gov.uk/nationalstudies/health/other/pages/aspoonfulofsugar. aspx (last accessed 22 April 2010). 4 Council GM. Tomorrow s Doctors [Online] Available at tomorrows_doctors_2003.asp (last accessed 22 April 2010). 5 Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for Tomorrow s Doctors. Br J Clin Pharmacol 2003; 55: Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for better prescribing. BMJ 2006; 333: Dornan T, Ashcroft AD, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Was V. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education EQUIP study. [Online] London: General Medical Council. Available at causes_of_prescribing_errors.pdf_ pdf (last accessed 22 April 2010). 8 General Medical Council. Tomorrow s Doctors. [Online] Available at Br J Clin Pharmacol / 70:1 / 147

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