Recuperación en evaluación extraordinaria
UNIDAD 9. El relieve y los procesos geológicos externos
A particular area of clinical practice which was highlighted in responses during all interviews was the preparedness to prescribe. This is one of the biggest steps in practice in the
transition from student to F1. Prescribing is described as consisting of two related but distinct areas: the basic science and pharmacological knowledge required to understand drug
effects, interactions and contra-indications, and the actual mechanics of prescribing, such as calculating dosage, and writing up a prescription and drug chart. One relates to a knowledge base, the other to practical and procedural skills, although both are equally important in the development of skilled practice.
13.1 Newcastle Graduates
13.1.1 Expectations of Newcastle Primary Sample
Prior to starting F1, prescribing was the area of practice that was most commonly reported by new graduates as a gap in preparedness to start work as a doctor. More than half the sample reported problems in this area.
“I think prescribing is the biggest, the biggest worry for me” (NPS224, first interview,
quartile 1)
The distinction between pharmacology and prescribing was highlighted by respondents:
“I feel fairly confident about prescribing a few drugs and I understand the principles of prescribing, I understand the actual process of doing it but I feel that my
pharmacology is severely lacking…a huge, huge gap” (NPS194, first interview,
quartile 1)
Some respondents were specifically critical of the teaching they had received in this area, but others saw it as an area in which they could only become proficient and confident once they started the job. However, they expected they would make mistakes. Illustrating the
heterogeneity of the sample, there were a few respondents who did feel prepared for prescribing, and did feel the teaching was adequate.
“Prescriptions aren‟t too bad because again we had a lot – we had teaching on that and sort of covered that a lot in medicine” (NPS24, first interview, quartile 4)
There were three people in the sample who had previous experience of prescribing from earlier, pre-medical school, employment, which gave them some confidence -but they also reported this was a weak area.
“…if it wasn‟t for the fact I prescribed before, I really would have no idea you know”
(NPS146, first interview, quartile 2)
Experience of Newcastle Primary Sample
At the end of their first placement, some F1s still felt they had been lacking in preparation for prescribing.
“I think the only real thing [that could have prepared me more for work as an F1] is medication, I think we should, I think we could have probably had a little more pharmacology teaching.” (NPS143, follow-up, quartile 2)
“Prescribing, we did not get much training about this, I‟ve had experience as an x [previous clinical training before medical school]. The pharmacology teaching was very poor” (NPS146, follow-up, quartile 2)
“We really never started in earnest doing any prescribing until the final year. It seems a bit late because we could make our mistakes earlier and learn from it.”
Some F1s took the view that prescribing was something that you could only really learn about once you started work and were able to apply knowledge in practice.
“I know now I feel confident to prescribe certain things. I think that was probably one of my more shaky subjects at Uni. You know things like learning doses and learning drugs when you haven‟t got a context to put it in it‟s really, really hard and it‟s just names.” (NPS224, follow-up, quartile 1)
Respondents felt well supported by pharmacists attached to wards and available to contact for advice either face-to-face or over the telephone. F1s also reported that pharmacists would contact them directly if an error was made, such as forgetting to sign a form, or even minor omissions.
“The pharmacists are always on the phone, like looking through the drug charts, making sure there‟s nothing wrong, so it‟s quite good in that sense, yeah.” (NPS181,
follow-up, quartile 2)
“The pharmacists on the ward are really good, easy to ask” (NPS93, follow-up,
quartile 3)
“I would say the pharmacists are pretty good in [Hospital], they usually tell you when you are making a mistake or what needs to be changed” (NPS182, follow-up,
quartile 2)
Some respondents found their knowledge of drugs was lacking, in terms of not being aware of some less common drugs, but also not being prepared for prescribing even common drugs.
“One of the things I‟ve noticed is doses of medication… obviously you are always going to come across drugs that you‟ve not used before and you do not necessarily know the dosages but I think you just feel a little bit silly when you don‟t know common doses” (NPS143, follow-up, quartile 2)
“…the whole interaction with different things [we were not prepared for that]”
(NPS108, follow-up, quartile 3)
“Prescribing was a big thing I just wasn‟t prepared for... you didn‟t know which drug of all the antibiotics or what doses, how many times a day and for how many days for example, all those sorts of things.” (NPS22, follow-up, quartile 4)
Many respondents mentioned the prescribing exam that they were all obliged to take (see section 13.6 below), and which the majority initially failed (the assessment requires they score 100% at some point during the year). Some referred to the strict marking of the exam.
“The prescribing exam… you have to get 100% and it‟s quite pedantic with marks. But it means that everyone ends up sitting the exam. I think it is quite good as it brings you up to speed a bit on what you maybe should have been doing in the final year of med school”. (NPS65, follow-up, quartile 3)
“I failed my prescribing exam. I prescribed paracetamol and wrote on the kardex “paracetamol qdf” and everything else was fine and [only] I put one of the times, 8 o‟clock, and so failed my prescribing exam because I missed out the
time...paracetamol you give four times a day or regular analgesia and the pharmacist wrote on the paper „why on earth is paracetamol prescribed once a day?‟” (NPS209, follow-up, quartile 1)
Mistakes
Respondents reported making more errors in the area of prescribing than in any other area. This may be in part because of respondents‘ sensitivity to the issue, rather than a real higher incidence, as some of the errors were very minor.
“I mean there‟s obviously things like getting drug dosages wrong because you are not familiar with the drugs or, you know, you confuse it with something else when you are prescribing it” (NPS24, follow-up, quartile 4)
“I prescribed something to the wrong patient … but like luckily it was only some peppermint capsules. But it was while I was on nights … so I was very tired”
(NPS93, follow-up, quartile 3)
However even minor errors may have impacts on patient wellbeing, and some were of more significance.
“Maybe prescribing the wrong type of analgesic”. (NPS194, follow-up, quartile 1) “I made one mistake where I didn‟t prescribe a man something which the registrar has asked me to prescribe… I just forgot… which had some consequences for the patient… because the man had a fit” (NPS66, follow-up, quartile 3)
Some errors were attributed not to failures of knowledge or practical skill, but to the pressures of working in a pressurised environment.
“I‟ve actually not realised let‟s say that somebody was on maybe two blood pressure tablets already rather than one...that‟s the kind of thing, I mean it‟s not you know a major mistake… when you‟re under a lot of time pressure, you‟re asked to sort of do several things at the same time and sometimes it ends up being a twelve hour shift and sometimes it‟s possible to misread things…I think once I may have prescribed somebody erm co-codamol and codeine” (NPS9, follow-up, quartile 4)
13.1.2 Newcastle Triangulation
Respondents in the triangulation sample identified an imbalance in the extent to which the undergraduate programme addressed the two elements of prescribing, with the
pharmacological knowledge underlying prescribing practice lacking.
“I think we have upped the stakes in the exams about the nuts and bolts of writing a prescription if you like and working out the dose and I think those skills are probably a little bit better but I think that the students‟ knowledge of pharmacology doesn‟t always appear very great on the ward, say for drug reactions or you know what to do with allergies etc…I would say there is more of a gap in that domain” (N
Undergraduate Tutor 2)
There was recognition though that despite its scientific basis there are aspects of prescribing that can only really be developed with experience of real, complex cases.
“…although we teach them about drug treatments and…they write about the choice of drug treatments and doses and what have you, but you are never quite sure how much that will generalise out into real life clinical situations ... I suspect that is an area where they will probably need quite closely supervised clinical practice in that situation” (N Undergraduate Tutor 1)
“I think the prescribing issue, you know, until you have actually been in a position where you are regularly prescribing…I think it is unreasonable to expect that they should always hit the mark every time especially when, you know, it has taken a lot of us quite a few years to achieve” (N Undergraduate Tutor 6)
Summary of ‘Prescribing’ for Newcastle graduates
Prescribing was the area of practice that was the most commonly reported in terms of lack of preparedness for practice. Prescribing was also identified as the weak area by a small
subgroup of graduates who had learned about prescribing prior to starting medical school. Concerns focused on: knowledge of pharmacology, choice of drugs, the practicalities of calculating dosages, as well as concerns about interactions and contraindications. Some graduates were critical of the teaching but some were of the view that this was an area that needed to be learned during practice.
At follow-up prescribing continued to be an area of concern. Some F1s reported that they felt the medical school could have prepared them better, whereas others reiterated that it was something that needed to be learned in practice. Lack of knowledge covered the full range from not knowing which drugs to prescribe to calculating doses. Generally the F1s had been well supported by the pharmacists who provided regular assistance and feedback. More errors were reported as being made in relation to prescribing than any other area of practice. A perception from the triangulation data was that the ability to prescribe was a major step up in a new F1‘s practice. The clinicians concurred with the views from the F1s about what the problems were – again, a range of areas were named ranging from gaps in pharmacological knowledge to problems calculating dosages and writing prescriptions. There was recognition that these are skills which can only be developed with real patients in the workplace.
13.2 Warwick Graduates
13.2.1 Expectations of Warwick primary sample
Most final year medical students felt that they were not prepared because there was “too little
emphasis on practical applications e.g. explaining BNF, writing up drugs and dosages”
(WPS6, first interview, quartile 3)
“For me the major one is practical pharmacology because we spent a lot of time studying pharmacology and I really don‟t feel very prepared for that in a practical kind of way.” (WPS4, first interview, quartile 1)
“I think, on that course it would have been useful to have more practice of filling in drug charts and prescribing oxygen, particularly, writing up regimes for warfarin and insulin, sliding scales, which, although they've been mentioned in passing over the four years, I don't feel particularly confident about exactly how to write them up, particularly things like the sliding scales: they vary from hospital to hospital even within the same trust. So I think I don't feel as prepared for prescribing drugs”
(WPS15, first interview, quartile 3)
“I think what would have been good is to explain the resources available, so the BNF and various other prescribing tools around the ward just because you can‟t get to know every drug so in that sense it would have been good teaching what to use and how to use it.” (WPS11, first interview, quartile 2)
“My proposal would be that in the first year we have a receptor mechanism course where you just get the idea of transmitters and how receptor mechanisms work, and then the next stage would be a course in general and systematic pharmacology of each system, and the pharmacology that goes with that system, and then a solid course on prescribing and, you know, what's expected of you. And just, I think, repetition in that respect would help.” (WPS23, first interview, quartile 4)
Respondents felt generally unprepared for prescribing as they approached F1. Some felt the relevance of pharmacology teaching during the undergraduate programme had not been apparent, and that it could be better placed in the course, although some knowledge gained during clinical placements had been useful.
“For me I didn‟t feel the pharmacology exam and the teaching actually had any impact on my useful knowledge or my future practice to be honest. The only thing that‟s changed my knowledge of pharmacology is having good medical blocks where the consultants have pushed [my] knowledge of pharmacology.” (WPS20,
first interview, quartile 4)
“I don‟t think it [the course] prepared me to implement pharmacology. It‟s such a huge part of medicine” (WPS13, first interview, quartile 3)
Particular issues referred to by respondents included a lack of knowledge about drug selection and calculating dosages, even for common drugs. Some felt that there was too much breadth in coverage of the subject area, and that there should be a focus on the drugs most often used on the wards. Some also felt that the exam should be a guide for what final year medical students are expected to know.
“I don't think that that course prepared you well for the everyday drugs you'll be prescribing as an F1.” (WPS5, first interview, quartile 1)
“I don‟t feel I know all the drugs well enough. … Prescribing is an area that I‟m probably most apprehensive about. …. You just don‟t want to get it wrong.” (WPS13,
first interview, quartile 3)
The practical side of prescribing was also referred to, such as writing up drug charts on the ward round and prescribing under pressure.
“I am sure I will get training and stuff but obviously when it is on a real person it is a bit different and you are worried “oh my gosh” what if I do something wrong?”
(WPS21, first interview, quartile 4)
“I think we were taught how to prescribe things fine, but I think I‟m still worried about that because I‟ve never done it before, so prescribing I think is going to be a bit scary for the first few times. That‟s not because of the prescription but timing wise. I‟m going to want to look it up, formulae first and check it but won‟t have time to do that.” (WPS17, first interview, quartile 3)
“We‟ve gone through a few drug charts over the last few days and people in the team have been quizzing me on what to do analgesia wise, and if someone has a temperature and things like that...I think I‟m going to be quite anxious about it and terrified about putting a decimal place in the wrong place ...especially as I‟m doing a paediatrics job” (WPS14, first interview, quartile 3)
However, some respondents who felt reasonably prepared for prescribing based this on the assumption that they would not be making major decisions independently, and that there would be support available from seniors and pharmacists, and information and guidance available in the BNF:
“Prescribing I guess I am not too worried about. In F1 you don‟t make too many decisions as far as major things go so I think most things I would be aware of what to do....as an F1 I can‟t actually see that being a problem.” (WPS4, first interview,
quartile 1)
“I‟m reasonably happy where it comes to prescribing because I know for a while I‟ll be looking in the BNF or asking the pharmacist to know that what I‟m prescribing is appropriate for that patient.” (WPS8, first interview, quartile 2)
“There are adequate guidelines and you can also ask seniors, refer to the BNF or ask the clinical pharmacist. I think gradually with time that would push the
confidence but we have been taught adequately I feel.” (WPS19, first interview,
quartile 4)
This person also indicated that he or she would adopt a cautious approach when prescribing.
“I know that there are certain drugs which are red flag drugs to me, like warfarin. A certain amount of drugs, you look at them and you think that‟s generally okay, I'll just start on a very low dose and just see how it goes, but there are other drugs you‟ve got to be careful of them. That is just knowledge, and I do have drugs which I know are red flag drugs and that I will be careful with. I feel that my pharmacology
knowledge is okay.” (WPS16, first interview, quartile 3)
One respondent felt confident with prescribing because he or she had completed a
pharmacology degree. A few final year students expressed general concerns about making mistakes, but this was not much in evidence except for prescribing.
13.2.2 Experience of Warwick primary sample
As anticipated, prescribing was indeed an area most respondents felt less prepared for during their first placement. Key issues mentioned by the sample were the selection of appropriate drugs; when to start a drug; determining and calculating dosages, particularly in more difficult cases (e.g. renal failure); and making decisions in more pressurised situations, such as under time pressure or on call where there is less support. In these situations
respondents sought a second opinion or advice or guidance from whoever was most appropriate in the circumstances - the pharmacist, a senior doctor, microbiologists or experienced nurses. This support from others is double-checked against the BNF. Prescribing was an area that some were certainly initially apprehensive about and less prepared for.
“I think prescribing was an area which I think was, at the start, very difficult. You second-guess yourself on every prescription. Was this safe? Was this correct?”
(WPS17, follow-up, quartile 3)
“Initially I was very slow.” (WPS19, follow-up, quartile 4)
Concerns about familiarity with common drugs expressed in the first interview were quickly alleviated with practice.
“We are getting more and more used to it and learning the normal dosages of common drugs. We pick that up quite quickly, but I don‟t think I was fully prepared for that.” (WPS24, follow-up, quartile 4)
“After a couple of weeks you get your own formula, your own list of medications that you prescribe regularly, and you prescribe again and again, and you‟re familiar with those. Drugs that you do not prescribe regularly you are more worried about”
(WPS1, follow up, quartile 1)
The distinction between pharmacology and prescribing practice was made in comments from respondents, with greater uncertainty remaining in their pharmacological knowledge and applying that knowledge, rather than prescribing procedures.
“I was okay with the technicalities of how to prescribe, but my knowledge of
appropriate drugs was, and still is, I think, very limited.” (WPS20, follow-up, quartile
4)
“Selecting drugs is quite hard to do on your own, because you are new to the thing, but again, hospital guidelines are there and hospital policies, and if you follow those you can‟t go too far wrong.” (WPS11, follow-up, quartile 2)
For some, calculating dosages was not an issue as there was thought to be enough written guidance (either the BNF or pocket-sized information provided by the hospital). Others thought it would be an issue if they were under time pressure as it is not always feasible to look it up or because there is less opportunity to get a second opinion from more experienced staff.
“Things like morphine. The first time I was on call I had a call saying can you up this morphine dose and you don‟t really know.” (WPS 4, follow-up, quartile 1)
Some referred to the prescribing assessment, which the cohort had not performed well at.