Prescribing Skills Assessment

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Prescribing can be a challenge for new medical graduates. Yet most of the prescriptions in hospitals are written by junior doctors. In a world where medication errors can cause serious harm to our patients, could or should we be doing more to teach safer prescribing? I'm Dr David Liew, your host for this episode, and today I'm speaking to two of the people who are part of a collaboration doing something about this. Associate professor Claire Harrison, a GP from Monash university who's in practice in Melbourne, and Professor Sarah Hilmer, the clinical pharmacologist and geriatrician from the Royal North Shore Hospital and the University of Sydney. They've written an editorial in the October edition of Australian Prescriber on the prescribing skills assessment and they join us here on the podcast today. Claire and Sarah, welcome to the program.

CH: Thanks very much, David.

SH: Thanks, David.

So let's talk about this in some detail. Is there a problem with prescribing skills in this country? What evidence is there for that and why does it really matter, Claire?

CH: David, there is an issue with medication-related problems and errors in prescribing will contribute to many of these. Thousands of episodes of inpatient care have been associated with adverse effects due to medications. The annual cost of medication errors in this country has been estimated at $1.2 billion and there are also thousands of hospital admissions and emergency department presentations which have been attributed to medication-related issues and 50% of these were deemed to be preventable. So there is a problem with medication-related harm in Australia and prescribing misstakes will be the cause of many instances of this.

It's hard to ignore that, isn't it? It's often a bit of a ... Well, it's almost a silent problem in terms of what we see in clinical practice, but the impact is real. Sarah, where do you think that the root problem is for this? As a clinical pharmacologist and as a geriatrician, where did you see it coming from?

SH: Look, David, I think that one of the main problems is that prescribing has become a lot harder in the last few decades. We've got increasing numbers of medicines, increasing complexity of the regimens and increasing multi morbidity in our patients. So when we ask our most junior medical graduates to do most of our prescribing, they're seeing people who take on average eight concurrent medicines and have on average six changes to those medicines made during the admission. It is a very complex, rapidly moving field. The other thing that I think has changed some systematic limitations to student learning of prescribing over the last few decades, in going to a graduate course in many cases and more of a integrated course, we've lost visibility of pharmacology teaching and formal prescribing teaching. We did a survey on interns during an orientation week a few years ago and we asked them about their teaching and prescribing and teaching and pharmacology.

One said, "What's pharmacology?" But when we actually tried to sort of quantify this across the whole 200 of the interns, 32% thought that they actually had an adequate understanding of common medications and their adverse effects, 84% said they would've liked to have more training in pharmacology as medical students, and actually 90% thought their training in pharmacology was actually not as good as it was in other medical areas. So it's something that changes in medical education has sort of left behind a little bit. I think also on the wards when students are on their attachments, they don't pay attention to prescribing because there are legal restrictions in what they're allowed to do. With the recent advent of e-meds, it's even harder for them to see what's going on. So in summary, I think our graduates need to have exceptionally strong skills to be able to prescribe in the really challenging and complex patient population and the multitasking environment that they're asked to work in as interns, and we're not really giving them that.

I can imagine that this problem isn't limited to Australia. Sarah, what has been done overseas in this area? Are there other precedents that we can follow or other places where we can look to be able to guide us on this?

SH: Look, David, it's really interesting that WHO currently has their third global patient safety challenge, which is called Medication Without Harm. The idea of this is to reduce severe avoidable medication-related harm by 50% over five years globally. The three themes that they have picked up on are transitions of care, so things around communication, high-risk situations, which covers the high-risk medicines as well as patients who are at particular risk, and polypharmacy. So countries around the world are getting together to try to make strategies on how they can deal with these three key issues. One of the main strategies that's been embraced is actually doing prescribing competency assessments.

A leader in this space is the UK with the UK Prescribing Safety Assessment. This has been disseminated to a number of other countries and a number of countries have as part of their response to the WHO challenge said, "We are going to put in a prescribing competency assessment."

So what do you mean by a prescribing competency assessment? What does that look like? What does that try and target and how well established is that as an idea?

SH: Competency assessments are reasonably well established in other fields of healthcare, but I guess less so in medical graduates. Generally we have standards for our medical graduates put out by the AMC and it's up to each medical school to demonstrate that their students have met those standards. A competency assessment actually tests that you can do something that you're going to need to do in practice, that you are work ready, and there's a move towards this kind of training in medical education.

The beauty of a competency assessment is that students study for exams, so if they know they're going to be tested on something, then they make sure that they can do it. So if prescribing competency is one of the things that you absolutely must do and demonstrate that you can do, then having a test or an assessment is a really good way to make sure it happens.

That kind of validation in terms of prescribing has never happened for our medical graduates previously. It seems like a well and truly overdue type of initiative.

SH: Look, I think in some places like the UK where this is probably the most advanced, it was really driven a lot by the patient safety agenda and by the need to really do something to make sure that our graduates were prescribing safely.

Well, what are we doing about it in Australia? Claire, you've worked on the prescribing skills assessment. What is it and how's it going to help?

CH: The prescribing skills assessment is an online teaching and assessment tool and it's based on the Prescribing Safety Assessment, which Sarah mentioned is from the UK. So it's been developed in the UK by a team from the British Pharmacological Society with the Medical School's Council. Then over the last number of years it's been regionalised to the Australasian context by a collaboration across 14 medical schools, involving almost 50 clinicians across multiple disciplines, both in medicine and pharmacy. So using this tool, the students have the opportunity in a safe, legal environment to practice multiple skills necessary for safe prescribing as they encounter virtual patients in both community and hospital-based settings. They have to write prescriptions, they have to identify adverse drug reactions and interactions. They need to calculate drug doses. They need to make decisions on pertinent information to communicate to patients and make plans to monitor the consequences of medication therapy, and they need to make adjustments to prescribing regimens, taking into account the results of clinical assessments and laboratory results.

In relation to how it's going to help, well, the tool is going to help as it gives our learners the chance to encounter and deal with many of the common sources of prescribing error before they treat real patients with feedback to help them optimise their performance. So through the use of the Prescribing Skills Assessment, the students develop skills in efficiently using the Australians Medicines Handbook to correctly choose the right drug, dose, timing, route, frequency and duration with a requirement to communicate clearly using safe abbreviations. They get to assess and manage those high-risk patient groups, the children, the elderly, those with polypharmacy, renal and liver disease. They get to manage all those error-prone medications and they also have to assess and manage multiple patients under time pressure, which is very much a skill expected from them upon graduation.

So so far through the use of the Prescribing Skills Assessment, there's been thousands of medication safety related questions marked with feedback given across Australian and New Zealand universities. It not only impacts on our students, but it has the potential to impact on our educational programs because we can analyse the results and the student feedback and then use it as an invaluable tool to inform ongoing curricular enhancement in medication safety.

I mean, it sounds like you've really thought through to make sure that there's something that's going to work and in practice. Sarah, for students, what do you think this is going to mean in practice?

SH: Look, David, I think it'll work well within the curriculum. It'll mean, I guess, three main things. Firstly, it'll mean that there will be more of a focus on learning about clinical pharmacology and prescribing because as I mentioned before students study for what's in the test. We've been talking with NPS MedicineWise who provide a fantastic online teaching curriculum around prescribing, and we think that this integrates very well with what they teach, and if we do identify gaps, there's scope to put in more modules to fill those gaps.

Secondly, I think in terms of logistically what it means, it means that they will have an opportunity to do some practice tests so they actually understand what they need to learn and what they're going to be asked to do. Then they will get to sit for an exam. As Claire said, this is an online exam. At the moment we're running it as a formative exam, but ultimately it may move to become a barrier exam. In the UK you absolutely have to pass this test before you can become fully registered. So ideally you pass as a medical student. If you don't, you have another chance when you're doing your supervised practice as an intern.

Then I think the third and biggest impact on students is that they will feel more prepared and confident to prescribe when they become interns, and hopefully they will make less preventable errors and do a better job and feel better about it.

Yeah. Great. So, I mean this is not the only thing that's been done in this space as well, is it, Claire? There are other initiatives in place that really compliment this as part of improving prescribing in Australia.

CH: Yeah, look, it's really important that we work to ensure that our graduates have adequate content, knowledge and practice in prescribing prior to their entry into the workplace. We believe that the Prescribing Skills Assessment will be a powerful tool to facilitate this. As Sarah has mentioned, there's an extensive range of excellent modules from the NPS MedicineWise, which are another educational initiative. Then there are a range of tools to support experiential learning on the wards with real patients under supervision and of course in general practice. But however, increased knowledge and practice alone are unlikely to be the sole solutions to reduce prescribing errors. So the workplace in which prescribers operate is a complex, busy one. There's frequent interruptions, there's competing demands, at times there's hierarchical structures and additional factors that can pose challenges to the individual's performance, including stress and fatigue. So therefore when we're thinking of educational initiatives, we need ones that also equip our learners with strategies to manage workloads, to practice self care, to speak up and be passionate patient advocates and champions for patient safety in the workplace.

It's also really imperative that our prescribers are taught to effectively work interprofessionally, especially with colleagues and pharmacy and nursing, who are key members of the team alongside with the patient as we all drive towards patient-centred care and shared decision making. For those of us out in the workplace already, we should ask ourselves, "Are we doing enough for our upcoming colleagues to minimise their risk of making errors? Are we ourselves speaking up to demand any necessary changes to the work environment to minimise its influence as a cause of medication errors and to engender a culture which is supportive, which is celebrating successes in medication safety, and learns from mistakes and really puts patient safety at the front and centre of activities?"

Yeah, I mean, it's really all part of trying to make our health system a better place and will give our prescribers a platform to help them make better decisions, really, isn't it?

CH: Yes. Yeah.

Well, it's been a pleasure speaking to you both today. There's more detail in the editorial talking through the Prescribing Skills Assessment, but thank you very much for joining us on the podcast today to both of you.

SH: Thanks, David.

CH: Thanks for having us.

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The views of the guests or the hosts of this program are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew, and thanks for joining us once again on the Australian Prescriber podcast.