Abstract
Adequate training in clinical pharmacology (CP) is considered essential to produce medical graduates who can provide safe and effective prescribing. National and international curriculums for CP teaching generally cover the following domains: knowledge and principles of CP, skills and attitudes [Orme et al. 2002; ASCEPT, 2011; CIOMS, 2012]. Two main approaches have been used by medical schools to objectively assess CP and prescribing competency: a list of core drugs, known as a student formulary, that students must know; and a list of common clinical conditions that students must be able to manage [Orme et al. 2002].
The Flinders University Medical School in Adelaide, Australia, has adopted the CP curriculum devised by The Australasian Society of Clinical and Experimental Pharmacology and Toxicology (ASCEPT) for its 4-year postgraduate medical course [ASCEPT, 2011]. No specific student formulary is used but a list of common conditions is provided to students in their penultimate year. There is no distinct CP topic in the medical curriculum at Flinders University. Instead, CP is integrated into ‘system’ based modules across the 4 years of study. CP teaching occurs through lectures, self-directed web-based learning, problem-based learning, case discussions, tutorials and opportunistic learning during clinical rotations. No objective assessment of CP skills, particularly prescribing skills, is performed throughout the medical curriculum at Flinders University.
This approach to CP skills teaching and assessment is not uncommon. Less than 20% of UK medical graduates consider themselves to have undertaken a distinct CP course and less than 15% believe that specific assessment in CP was undertaken [Heaton et al. 2008]. By contrast, 60% of UK schools reported having a dedicated course in CP, although in most cases there was vertical integration [O’Shaughnessy et al. 2010]. The majority (90%) of schools also reported specific assessment of CP. Lack of signposting may contribute to a student’s lack of awareness of CP delivery and assessment [Ross and Maxwell, 2012].
Improving the CP skills of medical students can be achieved through e-learning programs, student formularies, interprofessional learning, preprescribing and ward-based tutorials focused teaching and greater clinical exposure [Scobie et al. 2003; Sandilands et al. 2011; Ross and Maxwell, 2012]. However, a systematic review of educational interventions to improve the prescribing of junior doctors showed a lack of high quality studies [Ross and Loke, 2009]. Other factors in addition to the structure and content of the medical curriculum can also affect student competency including personality, number and type of clinical placements, shadowing and the support of others [Illing, 2008]. Although most medical schools in the UK believed that their medical graduates were ‘well’ to ‘fairly well’ prepared, only 37% actually assessed graduate competencies [O’Shaughnessy et al. 2010].
There is no information on the adequacy of CP training and competency among final year medical students in Australia. In an online test survey, approved by the local ethics committee (SAC HREC, reference number 186.13), final year postgraduate medical students at Flinders University were asked to rate their subjective competency by responding to the question ‘How do you rate your pharmacology skills?’. This was assessed using a four-point scale: ‘extremely well prepared’, ‘well prepared’, ‘fairly well prepared’ and ‘not prepared’. Multiple choice questions relating to clinical scenarios were used to assess objective competency in therapeutic drug monitoring (4 possible responses) and ability to successfully identify (12 possible responses) and report adverse drug reactions (ADRs, 13 possible responses, Table 1 and Figure 1). The ability to take an accurate medicines history was assessed by asking participants to rate how frequently they ask about (1) prescription drugs, (2) over the counter medications, (3) herbal medications, (4) vaccinations, (5) ADRs, (6) adherence, (7) allergies and (8) changes to medications. Respondents had a choice of ‘always’, ‘sometimes’, ‘rarely’ or ‘never’. We used previously defined international criteria for achieving competency in the different skills [WHO, 2002; ASCEPT, 2011]. Ability to establish an accurate medicines history was achieved if respondents ‘always’ inquired about prescription, non-prescription, complementary medicines, ADRs and information on adherence to therapy.
ASCEPT standards and questions used to objectively assess clinical pharmacology competency in medical students.
Test questionnaire.
Competency in detecting ADRs was achieved if respondents considered the time course of drug action, withholding or reducing medications and alternative causes unlikely. Competency in reporting ADRs was achieved if respondents reported them to the Therapeutic Goods Administration either by email, telephone, online or via a blue Adverse Drug Reactions Advisory Committee form. Ability to monitor the therapeutic and toxic effects of drug therapy was defined as respondents correctly identifying that for the defined patient with epilepsy (Table 1), a slightly elevated phenytoin concentration in conjunction with good seizure control does not require dose adjustment (Figure 1).
A total of 58 of the 121 final year medical students answered the questionnaire (48% response rate). Half the students considered themselves as ‘not well prepared’, 23 (40%) as ‘fairly well prepared’, 6 (10%) as ‘well prepared’, and none as ‘extremely well prepared’. Overall objective competency was achieved in 10 out of 58 subjects (17.2%) compared with 29 subjects (50.0%) who subjectively rated themselves as being ‘fairly well prepared’ or ‘well prepared’. Only 24 of the 48 subjects identified as not being objectively competent overall rated themselves as ‘not well prepared’ (p < 0.001 for agreement). Two-thirds (65.5%) of participants were identified as being competent in relation to therapeutic drug monitoring. Competency was similar between those studying in urban versus rural areas, males and females, and students <28 and ≥28 years of age (Table 2). Of the 38 subjects (65.5%) who demonstrated competency, 20 rated themselves as being ‘fairly well prepared’ or ‘well prepared’, and of the 20 subjects not considered competent, 11 identified themselves as ‘not well prepared’ (p = 0.08 for concordance indicating poor agreement with subjective competency). Overall, 21 (36.2%) had the skills to correctly identify ADRs. A total of 12 considered themselves as being ‘fairly well prepared’ or ‘well prepared’. Of the 37 subjects who did not achieve competency, 20 considered themselves as ‘not well prepared’ (p = 0.12 for concordance indicating poor agreement with subjective competency). Relatively few students (n = 6, 10.3%) had the necessary skills to report an ADR. Each of these students trained in rural settings during their penultimate year in the medical school. Of the 6 subjects who demonstrated competency, 3 considered themselves as being ‘fairly well prepared’ or ‘well prepared’, and of the 52 subjects who did not achieve competency, 26 considered themselves as ‘not well prepared’ (p < 0.001 for concordance). Only three students had all the required skills to adequately take a medicines history. Students frequently asked about prescription and nonprescription medications but rarely inquired about adherence to treatment (Table 3). Of the 3 subjects who demonstrated full competency, 1 considered themself as being ‘fairly well prepared’ or ‘well prepared’, and of the 55 subjects who did not achieve competency, 27 considered themselves as ‘not well prepared’ (p < 0.001 for concordance).
Objective competency.
ADR: Adverse drug reaction.
Ascertainment of patient medication history.
Our finding that only 50% of students reported feeling prepared in CP skills is similar to that observed among medical graduates in other countries with similar medical curriculums. At the end of their first year as a postgraduate doctor, 63% of doctors in the Birmingham and Worcester regions of the UK reported receiving adequate undergraduate training in CP [Baldwin et al. 2012]. In Aberdeen, 56% of first year doctors thought their undergraduate teaching had prepared them to prescribe safely and rationally [Tobaiqy et al. 2007]. Our study also provides objective competencies in detecting and reporting ADRs, which have been described elsewhere by graduates as being poorly taught. In the UK, inadequate teaching of ADRs was identified amongst 42% of first year doctors and 60% reported insufficient teaching about drug–drug interactions during their university education [Tobaiqy et al. 2007]. At Flinders University only second year medical students receive formal lectures on ADRs with most CP teaching occurring informally within rotations and problem based learning. The poor agreement between subjective and objective CP competency observed in our study is in line with previous reports among junior doctors and medical students in a number of areas including prescribing medication [Ryan et al. 2013], skills in evidence based medicine [Lai and Teng, 2011] and clinical and procedural skills [Barnsley et al. 2004]. The mismatch between self-perceived and actual skill level has implications for student assessment, in particular the use and value of formative and self-assessment.
Our study has a number of limitations. First, the response rate was relatively low. There may have been a response bias with students who felt adequately prepared being more likely to respond than those that did not. However, this would have resulted in conservative estimates of the lack of subjective and objective competency. Second, the study may have lacked sufficient power to detect significant associations between demographics and objective levels of skill. Third, it was limited to one Australian university, meaning that the results cannot be generalised to other Australian medical schools or to students in other English speaking countries with similar curriculums. Larger studies designed to attract a better response rate and with more comprehensive assessment are required. Fourth, since the study was conducted midway through the final year of postgraduate medical studies, the results may underestimate the final competency achieved by the end of the year. Studies have shown that CP competency of junior doctors improves over time [Pearson et al. 2000; Harding et al. 2010]. However, it is unlikely that students would significantly improve their knowledge in the final 6 months of their course given the lack of formal CP teaching. The lack of a more comprehensive assessment of clinical pharmacology skills, particularly prescribing, did not allow a formal comparison with published studies. However, our preliminary results are an initial step for the development of local clinical pharmacology assessment methods as part of comprehensive assessment methods, e.g. the Objective Structured Clinical Examination (OSCE).
Footnotes
Conflict of interest statement
The authors declare no conflict of interest in preparing this article.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.