I sit watching a battle rage over my head. It has been raging for years and the battle lines are well drawn. Yet, in little more than 14 months, I can get up and skip around these troubles, care free.
I am talking about prescribing rights. The political powers have been thinking about extending them beyond doctors to include nurses, physiotherapists, and pharmacists. And current plans don't limit their formulary. Supplementary prescribers will soon be able to dole out anything they wish.
We have nothing like the 35 days' training that nurses get
Where do I come into all this? I am a medical student, coming to the end of my fourth year. In 14 glorious months someone will tap me on the head with a magic wand and I will be a doctor. I have just spent part of my elective working at the BMJ and, as part of that, I attended a conference last month about excellence in prescribing. As I listened to the presentations, the discussions, and the heated exchange between doctors, nurses, and pharmacists, I wondered just how excellent at prescribing I might be. I've not decided that one. However, while the conference touched on a wide variety of subjects, two main issues arose. The first was that many people thought that prescribing rights were being extended too quickly—this subject was enough to keep various experts debating for a whole afternoon. The second issue was about teaching medical students how to prescribe—this subject was discussed for only about half an hour.
I went to a workshop about nurse prescribing, to try to understand current developments. But it seemed that even nurses themselves were confused. And not surprisingly, as there are various levels of prescribing rights. Supplementary prescribers—formerly referred to as dependent prescribers—would be nurses and pharmacists working with a doctor under a clinical management plan, as proposed by the government in April. In theory, they would be able to prescribe most things, apart from controlled drugs and unlicensed medicines, but it is thought that they will be of most benefit to patients with chronic conditions, such as diabetes and asthma. Then there are independent prescribers, who, following training, would be able to prescribe all pharmacy and general sales list medicines prescribable by a general practitioner. They would also be able to prescribe from a list of around 140 prescription only medicines for minor injuries, minor ailments, health promotion, and palliative care.
Nurses who wish to prescribe will have to undergo special training. To be eligible for this, they must be qualified for at least three years. This training will amount to 35 days in total, and, even then, nurses will have to follow strict guidelines.
Lancet editor Richard Horton argued at the conference and shortly afterwards in his journal that prescribing rights were being extended too quickly. He said that nurses were being manipulated to fill the gap left by too few doctors. He also made some points that really do make me wonder about my own skills and competencies. “If prescribing rights are extended to all drugs in the BNF, nurses will need to know basic and clinical pharmacology, including the mechanism of action of drugs, pharmacokinetics, pharmacodynamics and how to appraise evidence from clinical trials.”
Where's my teaching on this? I had a series of lectures at the end of the second year that probably amounted to about eight hours. I'm not criticising my teachers—in fact, my university is lucky to have an excellent pharmacology teacher who is very engaging. But we have nothing like the 35 days' training that nurses get.
Professor Sir Charles George, who was chairman of the General Medical Council's education committee when it issued Tomorrow's Doctors, its recommendations on undergraduate medical education, told the conference that preregistration house officers were meant to be supervised in their work, and that the level of supervision would reduce as they progressed through the year. I wonder if this really happens. From what I have seen, house officers are generally left to get on with it on their own.
He also pointed out that it was difficult to learn about prescribing until you were actually doing it. It was like trying to learn a language without being allowed to speak it.
Student doctors are in the main a fairly conscientious bunch. I know that I will make sure that I can prescribe safely before magic wand day, and I would say that most of my peers will do the same. I just worry that as do it yourself, problem based learning formats become more popular with universities, will prescribing become another aspect of our training that we will be left to “pick up”?
Nurses are very highly skilled and if they need 35 days' training to prescribe, then what should medical students have?