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Keywords:

  • junior doctors;
  • medical education;
  • medical students;
  • prescribing;
  • teaching

Abstract

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

Aims

Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors.

Methods

One hundred and ninety-six tutorials were delivered to 183 students during 2010–2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis.

Results

The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors.

Conclusions

A ‘near-peer’ junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials.


What is Already Known on this Subject

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References
  • Avoidable adverse drug reactions and prescribing errors are common.
  • Independent studies suggest that undergraduate prescribing education may be insufficient to meet the challenges of modern healthcare.
  • Specific teaching in prescribing has been shown to improve prescribing performance, but most studies have focused on teaching by senior clinicians.

What This Study Adds

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References
  • ‘Near-peer’ prescribing tutorials increased the self-reported confidence, knowledge and prescribing skills of the participating students.
  • Tutors reported that participation in the programme improved their prescribing and also their ability to teach.
  • Most students preferred prescribing training delivered by junior doctors rather than their more senior colleagues.

Introduction

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

Avoidable adverse drug reactions and prescribing errors are common in hospitals and are a threat to patient safety [1-4]. A study commissioned by the UK General Medical Council showed that nearly one out of every 10 hospital prescriptions contained errors, and that most are made by the most inexperienced doctors, recently graduated from medical school [5, 6].

There have been concerns that undergraduate medical education may not provide sufficient emphasis on the principles of clinical pharmacology, knowledge of drugs and therapeutics, practical prescribing skills and supervised experience to meet the demands of being a junior doctor prescriber in a busy hospital setting [7, 8]. This may make it hard for students to make the rapid transition from student learner to busy hospital prescriber and may contribute to the sense of uncertainty felt by many new graduates [6, 8, 9]. Systematic analysis of medication errors cites inadequate training as an important contributing factor [6, 10-14]. The increasing recognition of the importance of improving education in this area is supported by accumulating evidence that dedicated teaching for prescribing improves performance [15-21].

Recognizing that junior doctors take responsibility for writing the majority of prescriptions in UK hospitals and that final year students, who are their immediate successors, often fail to get practical experience of prescribing, a ‘near-peer’ prescribing education programme was established in South East Scotland to bring these two groups together [22]. This programme was developed 5 years ago by collaboration between junior doctors and medical education staff who developed a series of commonly encountered clinical cases which were then used to deliver practical prescribing tutorials to final year medical students in a classroom environment. This programme aims to provide experience of prescribing and build confidence amongst senior medical students, whilst empowering junior doctors to develop as clinical teachers and achieve the teaching requirements of the Foundation Programme curriculum.

The aims of this study were (i) to evaluate the impact of this near-peer prescribing tutorial programme on the confidence and prescribing abilities of final year medical students and (ii) to explore the experience of junior doctor tutors in providing tutorials and the benefits and challenges of delivering this teaching.

Methods

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

Description of programme

Interactive small group tutorials were delivered by first and second (Foundation) year doctors to final year medical students at the University of Edinburgh. Junior doctor volunteers were first required to attend a tutor training day consisting of focused training workshops in teaching (including the principles of how people learn, clinical teaching, small group teaching and academic feedback), and simulation of prescribing tutorial sessions under the guidance of expert tutors from previous academic years. The tutorials were based on 10 acute clinical prescribing scenarios (Table 1). Tutorials lasted 1 h and were delivered throughout the academic year. Foundation doctors decided in advance which of the 10 scenarios they wished to deliver and then advertised tutorials for medical students to sign-up to on their online learning environment. A maximum of eight students were allowed to attend each tutorial in order to maximize the educational value for each. Participation in the tutorial scheme was voluntary and students attended whenever they did not have formal teaching elsewhere. Each tutorial began with discussion of a clinical vignette (an example is provided in Figure 1), which included the history, examination and investigations, before agreement was reached on the principles of clinical management. Students were then invited to prescribe their management on the drug administration and fluid prescription charts. These charts were then reviewed by the tutor and individual feedback was provided to each student to optimize all aspects of their prescribing for the given scenario (including drug choices, dose, route, frequency, duration, legibility, consideration of allergy status and completion of therapeutic plan). Tutors also provided general feedback to the group on prescribing practice, in particular with reference to a local guideline on gold standard prescription writing [23] which reflects the British Pharmacological Society's ‘Ten Principles of Good Prescribing’ [24]. The tutorials concluded with a discussion about further patient management and relevant prescribing principles.

figure

Figure 1. Example case vignette for a patient with diabetes ketoacidosis. The students discussed the clinical management before being asked to prescribe relevant medications and fluids

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Table 1. The 10 different tutorial topics that were covered by the prescribing tutorials
Acute medical emergenciesAcute surgical emergencies

Acute dyspnoea

Acute left ventricular failure

Anaphylaxis

Diabetic ketoacidosis

Hyperkalaemia

Paediatric prescribing

Acute appendicitis

Gastrointestinal bleeding

Intestinal obstruction

Road traffic accident (major trauma)

Programme evaluation

Students were asked to complete a questionnaire at the end of each tutorial delivered during 2010–2011. This contained their student matriculation number (for further analysis) although it was not possible to reveal the identity of students from these data. The questionnaire explored their prior experiences and attitudes towards prescribing, their experience of participating in the tutorial and the perceived impact of this training on their future prescribing. Tutors were asked to complete an anonymized questionnaire about their experience of teaching on the prescribing programme at the end of the academic year. This explored their experiences of the tutor training day prior to delivering teaching, their experience of teaching over the year and the perceived impact of their participation on their future teaching and prescribing practice. All questionnaire data were collected using a five point Likert scale and the mean for each question was calculated (out of a total of five).

The association between tutorial attendance and end-of-year examination performance in 2010–2011 was assessed by linking the student matriculation numbers with summative assessment outcomes. The undergraduate administration provided an anonymized spreadsheet with results broken down by individual components of the final assessments (drug prescribing station, fluid prescribing station, an on-line examination ‘Safety in Practice and Prescribing’, history taking station, clinical examination station and an oral examination which assessed ‘vertical themes’ within the curriculum including clinical communication and medical ethics). The prescribing stations assessed the same principles of prescribing which were reviewed in tutorials, although the clinical scenarios differed. The students’ examination performance was analysed using linear regression which has been presented as a correlation coefficient with two-tailed t-test (P < 0.05 was considered statistically significant). Approval for this study was granted by the University of Edinburgh's Advisory Committee on the use of Student Volunteers.

Results

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

Student participation

One hundred and eighty-three (81%) of final year medical students at the University of Edinburgh attended at least one of the 196 tutorials which were delivered between September 2010 and May 2011. Students attended between one and 10 tutorials throughout the academic year. An average of 6.1 students attended each tutorial. One thousand and thirteen questionnaires were returned by attendees in total (86% response rate).

Overall quality of tutorials

Students were asked to rate the overall quality of prescribing tutorials: 75% reported them as ‘excellent’, 23% as ‘very good’, 2% as ‘good’ and no students reported them to be either ‘average’ or ‘poor’.

Student benefits from tutorial attendance (Table 2)

Table 2. Mean Likert scores of perceived benefits of tutorial attendance for students and impact of tutorial attendance on future activities
  1. Likert scores were 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree.

I felt confident about prescribing for this scenario before the tutorial2.80
I now feel confident about prescribing for this topic4.38
The tutorial advanced my knowledge4.55
The tutorial advanced my skills4.46
The tutorial was useful revision4.57
I was happy with the feedback given4.50
Junior doctors are the best people to deliver these tutorials4.48
I have written a drug chart on the ward before, under supervision4.22
I am now more likely to help write a drug chart before graduating4.32
I want to attend more tutorials4.49
Attending these tutorials makes me interested in teaching others4.73

Few students reported that they felt confident in prescribing for a given scenario before attending that tutorial. However, after attending the tutorial most students reported improved confidence in prescribing for that scenario. The students also felt that attendance improved their prescribing knowledge and skills in general. Almost all students reported that the tutorials provided useful revision. Students also reported feeling happy with the feedback given to them. They also perceived a benefit from their teachers being junior doctors with 95% of students reporting that they believe junior doctors are the best group of staff to deliver these prescribing tutorials compared with senior doctors.

Impact of tutorial attendance on future prescribing practice (Table 2)

Most students had already written a drug administration chart under supervision in a clinical setting. Following attendance at prescribing tutorials, students reported that they felt more likely to write drug administration charts before graduating. Ninety-nine percent of students were keen to attend further prescribing tutorials, and the majority reported that attendance had made them more interested in teaching others in the future.

Student examination performance

Over 60% of students reported that their primary reason for attending the prescribing tutorials was to pass their examinations. At the end of the academic year the association between tutorial attendance and examination performance was analysed and students attending more tutorials tend to perform better in the prescribing components of their final examinations (a weak but significant association, Figure 2). Students attending more tutorials also tended to perform better in some assessments not directly related to prescribing (history taking r = 0.17, P = 0.009 and examination skills r = 0.17, P = 0.011 stations). However this was not significant for the viva examination where statistical significance was not reached (r = 0.11, P = 0.090).

figure

Figure 2. Correlation between tutorial attendance and performance in the end of year examinations (the three examinations which directly assessed prescribing skills: A) r = 0.16, P = 0.015; B) r = 0.18, P = 0.007; C) r = 0.22, P = 0.001

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Tutor participation

Thirty-seven junior doctors (30 Foundation year 1 and 7 Foundation year 2 doctors) delivered 196 prescribing tutorials over 2010–2011, with an average of 5.3 tutorials delivered per tutor (range 1–20 tutorials). All tutors returned their questionnaire at the end of the year.

Preparation and practicalities of delivering teaching (Table 3)

Table 3. Mean Likert scores of tutor training feedback, scheduling and experience of delivering tutorials, and perceived benefits of teaching
  1. Likert scores were 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree.

I found the tutor training day improved my teaching skills4.12
I would have liked more teacher training than was provided2.94
I was able to teach at a time convenient to me4.25
I was able to teach during allocated work shifts2.14
I was able to leave my ‘bleep’ (pager) with a colleague2.26
I enjoyed teaching on this programme4.69
I felt confident teaching final year medical students4.28
I was able to provide good feedback to my students4.31
I frequently addressed important misunderstandings or deficits in student knowledge3.81
I was asked questions that I did not know the answer to2.94
I have improved my prescribing knowledge by teaching4.42
I have improved my prescribing practice by teaching4.17
I feel more confident as a clinical teacher4.47
I feel more prepared to teach4.47
I have more enthusiasm for prescribing teaching4.42
I want to do more to improve my teaching skills4.56

In preparation for teaching on the programme tutors attended a compulsory tutor training day. Eighty-one percent reported that this improved their teaching skills, although 24% would have liked additional teacher training. All tutors reported being able to teach at a time convenient to them. However, this was mostly in their own time as only 14% of tutors were able to teach during working hours. Of those who were able to teach during their working hours 64% were able to leave their ‘bleep’ (pager) with a colleague whilst teaching.

Experience of teaching (Table 3)

All tutors enjoyed teaching and most felt confident when teaching on this programme. All tutors felt equipped to deliver useful feedback to their students. 80% of tutors frequently addressed important misunderstandings or deficits in student knowledge. However 32% of tutors were asked questions that they did not know the answer to throughout the year.

Tutor benefits from teaching (Table 3)

Ninety-four percent of tutors perceived that their prescribing knowledge had improved and 80% considered their prescribing practice to be better as a result of teaching on this programme. All tutors reported feeling generally more confident as a clinical teacher and 94% felt more prepared to teach in the future. Ninety-one percent reported that they now have more enthusiasm for prescribing teaching and 97% would like to do more to improve their teaching skills.

Discussion

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

The major findings of our study were that (i) students and junior doctors both considered that their prescribing confidence had improved as a result of attending prescribing tutorials; ii) there was evidence of a positive association between tutorial attendance and examination performance; (iii) misconceptions and deficits in student knowledge seem to have been frequently addressed; (iv) students expressed a preference for prescribing training delivered by junior doctors compared with senior doctors; and (v) the tutorials harnessed enthusiasm for future teaching for both students and tutors.

This prescribing tutorial programme seems to be greatly valued by local medical students and junior doctors. There are several benefits perceived by students from participating in prescribing tutorials. Firstly, their confidence in prescribing for specific scenarios and prescribing in general is improved. This helps to address previously expressed concerns about prescribing confidence as students make the transition to graduated prescribers [25]. Students also reported that they were more likely to prescribe under supervision for real patients following attendance at tutorials to consolidate learning. Our data provide evidence of an association between tutorial attendance and improved examination performance. This was particularly true of assessments which directly assessed prescribing skills, but also of other examinations which assessed history taking and clinical examination skills. This may be explained by the structure of prescribing tutorials which incorporate discussion of relevant history taking and clinical examination skills as part of the tutorial experience. However, the Viva examination results did not correlate with tutorial attendance in a statistically significant fashion, which is not surprising given that this assessment does not cover any of the principles or skills acquired during attendance at prescribing tutorials. Although this association exists, we cannot attribute a causal relationship and it is feasible that better performing students were more likely to attend tutorials. This is in keeping with previous literature [15-21]. However further research is required to determine to what extent such educational interventions directly influence subsequent prescribing performance. Tutors also seem to benefit from improved knowledge and confidence in both prescribing and teaching. This is partly related to the preparation undertaken before teaching now that tutor training has become compulsory prior to delivering tutorials. This was made compulsory to provide further support to our tutors, to improve their teaching [26] and ensure best practice as per the General Medical Council recommendations [27, 28] on teacher training.

Tutors are encouraged to provide feedback to students, which students appreciate as this tutorial programme provides the opportunity for tailored feedback on prescribing practice which may not be available elsewhere during the curriculum. Many tutors reported that they frequently addressed student misconceptions and deficits in knowledge throughout the year that might otherwise have been carried through to clinical practice. This highlights the strength of these tutorials in identifying areas of uncertainty which could potentially otherwise predispose to medication errors. However, around one-third of tutors were asked questions by students which they were unable to answer at some stage over the academic year. As part of training, tutors are encouraged to be aware of their own limitations [29] and where unable to provide a definitive answer to students are advised where to direct the students to answer their query or to find out the answer and contact the students again at a later date.

Another benefit of this tutorial programme is that most medical students indicated that they preferred junior doctors to deliver this prescribing teaching compared with more senior colleagues, and these benefits of using junior doctors as teachers have been recognized elsewhere [30]. Possible reasons for this include the recent experience of junior doctors in the student's curriculum (most of the tutors had been through the same examinations only a year or two previously), the approachability of junior staff and ease with which students can ask questions, and the insights provided from junior doctors which they have recently learned ‘on the job’. Furthermore junior doctors are responsible for most hospital based prescribing [31] and are perhaps the most appropriate group of doctors to deliver this form of teaching.

The tutorial programme also encourages the development of other professional skills amongst both students and tutors. Students reported that they are more interested in teaching as a result of participation in tutorials. Tutors feel more confident as clinical teachers and report being more prepared to teach in the future. They also reported more enthusiasm for prescribing teaching, which will help with ensuring the future sustainability of this programme. This may also encourage and promote the development of new initiatives which will further improve prescribing practice. However, most tutors are teaching in their own time outside of working hours and this may limit the opportunities for students to benefit from attending these tutorials, not only in terms of the number of potential tutorials being offered but also the timing students can attend. We encourage local education providers and educational deaneries to consider allocating dedicated teaching time for junior doctors to deliver prescribing education to medical students particularly as this is likely to improve patient safety, though we also recognize the challenges and priority of clinical service delivery.

A potential concern regarding our ‘near-peer’ model of prescribing training is that the junior doctor tutors lack professional teaching and prescribing experience and training and are a group known to perpetrate prescribing errors. We have taken several steps to mitigate these concerns. These include standardization of clinical vignettes, implementing a compulsory teacher training day and using post-tutorial student feedback to identify perceived limitations from the learner's perspective. In addition, the university lead for clinical pharmacology and prescribing education (SM) has provided academic supervision from the inception of this prescribing tutorial programme including review of tutorial content and tutor training. A further important point is that senior clinicians also make prescribing errors on a regular basis [5]. We believe that any concerns about the slightly higher error rate found between junior and senior prescribers is more than offset by the potential of junior doctor-led teaching to provide greatly enhanced workplace-based prescribing experience. Other potential strategies for ensuring quality in the future might include greater external review of the tutorials by senior trainers, better assessment of outcomes and enhanced tutor-tutor contact and discussion during the tutorial programme.

This study has several important limitations. First, although 81% of final year students attended tutorials, they were self-selected and so may not necessarily be representative of their year group. Factors which may have accounted for not all students attending these tutorials include the availability and timing of tutorials, some students preferring only staff teaching and some students feeling that the tutorials were not necessary. Second, questionnaires were completed immediately after each tutorial and, although responses would not have been attributable to a specific student, were collected by the tutor and so this may have influenced student responses. Third, we report the opinions of the tutors and students about the value of this programme but cannot know what the actual benefits are to tutors, students or patients.

In conclusion, this near-peer prescribing programme is a highly valued model for teaching clinical prescribing to medical students. The programme helps to address a significant unmet need for prescribing practice at a time when this has become more difficult due to busy clinical environments, and where job plans mean that senior clinicians are less able to provide a large number of small-group practical prescribing tutorials. The programme also encourages the development of additional professional skills, including interest in teaching others, which is important in ensuring the future sustainability of this teaching programme.

Competing Interests

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References

All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work.

We thank the tutors and medical students for participating in this teaching programme and its evaluation. We are also grateful to those who contributed to the tutor training days (in particular Debbie Aitken, Helen Cameron and Vicky Tallentire), to the University of Edinburgh Centre for Medical Education for funding these training days, and to Neil McCormick and others in the undergraduate College Office for providing the assessment data.

References

  1. Top of page
  2. Abstract
  3. What is Already Known on this Subject
  4. What This Study Adds
  5. Introduction
  6. Methods
  7. Results
  8. Discussion
  9. Competing Interests
  10. References