Evaluation of a short-structured learner-centric training program on rational drug prescribing for medical interns: A quasi-experimental study

ABSTRACT

Introduction:

Rational drug prescribing skills of interns remain bleak despite clinical pharmacology training during their second year, warranting the need for further training. This study was designed to evaluate the effectiveness of a short-structured learner-centric training program using the World Health Organization (WHO) guide to good prescribing in improving interns’ knowledge of rational drug use and their rational drug prescribing skills.

Methods:

This quasi-experimental study was implemented at a tertiary care teaching hospital in South India. We conducted a short-structured learner-centric training program on rational drug prescribing for interns in September 2022, using the WHO guide to good prescribing. The medical interns who consented to participate were included in the study. A pre-test was administered at the start of the training, followed by a post-test and feedback questions at the end of the program. Statistical tests used for quantitative data were the Wilcoxon signed-ranks test and McNemar’s Chi-square test. Qualitative data were analyzed using manual content analysis.

Results:

Of the 77 interns who attended the training program, 73 provided consent and completed both the pre-test and the post-test. Their mean age was 22 years, with a slight preponderance of female participants (53.4%). Overall, there was a statistically significant increase in the median (interquartile range) total scores from 52 (44.6 – 60) to 84 (70 – 88) after the training (P = 0.001), out of a maximum score of 93. Also, a significantly greater number of them wrote legible prescriptions (grade 4/excellent – 44 in pre-test vs 52 in post-test; P = 0.001) after the training.

Conclusion:

The short-structured learner-centric training program based on the WHO guide to good prescribing significantly improved the knowledge of rational drug use and rational drug prescribing skills among medical interns.

Introduction

Irrational drug use is highly rampant across the globe and wreaks havoc on people’s health and the nation’s economy. As per the World Health Organization (WHO), more than 50% of all medicines are prescribed, dispensed, or sold inappropriately, and 50% of all patients do not take them correctly.[1] Also, it is estimated that at least half of the average family expenditure on medications is attributed to unnecessary drugs or diagnostic tests.[2] Thus, promoting rational drug use is of paramount importance to maximize therapeutic outcomes, avoid preventable adverse drug reactions, and minimize the cost of drug therapy.[3]

According to the WHO, rational use of medicines requires that “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.”[1] Rational prescribing is one of the essential components of rational drug use, and the WHO has developed a handbook on “Guide to Good Prescribing” in an attempt to equip physicians with the required skills for rational drug prescribing.[4]

The internship is when undergraduate medical students are directly involved in patient care and develop the habit of drug prescribing in real-time. Although the rational drug prescribing concepts including the definition and advantages of rational drug use, P-drug concept, prescription writing, and prescription auditing skills are taught during their pharmacology classes during their second-year MBBS training, their practical drug prescribing skills remain weak due to a lack of contextualization of learning with the patient.

Various studies have found that knowledge of rational drug use and rational drug prescribing skills is poor among interns.[5,6,7,8] The majority of the prescriptions written by them were incomplete and not adherent to the WHO standards.[6,8] Thus, it is evident that clinical pharmacology training during their second-year MBBS is not sufficient, and training of interns in concepts of rational drug use is warranted. However, due to their tightly packed schedule and involvement in patient care activities, it is difficult to engage them in training programs of longer duration. Thus, there is a need for short innovative training sessions to recall their knowledge and skills. Thus, this study was designed to evaluate the effectiveness of a short-structured learner-centric training program using the WHO guide to good prescribing in improving interns’ knowledge of rational drug use and their rational drug prescribing skills.

Methods

This quasi-experimental study was conducted at a private tertiary care teaching hospital in Puducherry, South India. Institutional ethics committee approval was obtained (EC/42/2022), and the study was conducted according to the Good Clinical Practice guidelines and the Declaration of Helsinki. Written informed consent was obtained from the study participants.

A short-structured learner-centric training program on rational drug prescribing was conducted for interns, in September 2022. The training sessions were planned to be conducted in three batches for a total of 120 interns, with 40 participants allotted to each batch, over 3 consecutive days. This was conducted to maximize the interaction between the facilitators and the students. The training session lasted for two and a half hours, excluding the time allotted for pre-test and post-test. Attending the program and willingness to participate in the research was voluntary. Flow diagram showing study methodology has been illustrated in Figure 1.

Figure 1.

Flow diagram showing study methodology

Pre-test

The participants were asked to define rational drug use and P-drug, and enumerate the steps in rational prescribing. They were given similar four case scenarios for writing rational drug prescriptions. The case scenarios pertained to morning sickness [Refer Box 1], iron deficiency anemia, type 2 diabetes mellitus, and uncomplicated acute bacterial sinusitis. These scenarios were chosen considering the common disease conditions encountered by a primary care physician in our locality. The participants were given 20 minutes to complete the pre-test.

Box 1.

Case scenario on morning sickness for prescription writing exercise (pre-/post-test)

Short-structured learner-centric training program—interactive lectures with hands-on small group activities

During the training program, there were interactive PowerPoint presentations on rational drug prescribing based on the document “WHO Guide to good prescribing.”[4] It was a two and a half an hour training with hands-on sessions. The lecture covered the definition of rational drug use, the implications of irrational prescribing, the P-drug concept, and the steps involved in rational prescribing. Then, for small group activity, the students were divided into five sub-groups, each consisting of 5–6 students. The students in each group were seated in horseshoe or U-shaped manner to encourage better interaction among group members. Group tasks included choosing a P-drug and verifying its suitability, prescription writing activity, and giving instructions and warnings for various case scenarios taken from the WHO guide to good prescribing. Initially, the students discussed among themselves, and then, one student from each group presented their answers to the class. The facilitators moderated the session and provided input after each presentation.

Post-test and feedback

At the end of the training session, for the post-test, we administered the same pre-test questions for 20 minutes. Also, we elicited participants’ feedback on facilitating factors for learning and suggestions for improvement.

Scoring of the pre-/post-test forms

The pre-test and post-test forms were scored based on the self-developed scoring guide as mentioned in Table 1. The scoring guide was prepared in consultation with three subject experts in pharmacology.

Table 1.

Scoring guide for assessment of pre-/post-test forms

Questions/items	Score for correct response
Definition of rational drug use	4 (appropriate drug—1; appropriate dose—1; appropriate duration—1; appropriate cost—1)
Definition of P-drug	3 (correct response includes terms, such as “drugs regularly prescribed” or “drug familiar with”)
Enumerating the steps in rational prescribing	6 (each step written correctly is scored 1)
Task on prescription writing (four case scenarios)
Superscription
Date	10 (1 score each); 40 for four prescriptions
Prescriber name
Prescriber registration number
Prescriber address
Patient name
Patient age
Patient gender
Patient address
Diagnosis
Symbol Rx
Inscription
Choosing correct drug	8 (1 score each); 32 for four prescriptions
Drug formulation
Route of administration
Drug name in capitals
Drug name in generic
Drug dose
Frequency of administration
Duration of administration
Subscription
Instructions to patient	2 (1 score each); 8 for four prescriptions
Prescriber signature

Thus, the maximum possible score of a participant for each prescription will be 93

Also, the legibility of the prescriptions written by the interns was graded based on the following subjective grading scale:[9]

• Grade 1 (poor): Illegible

• Grade 2 (average): Most words are illegible

• Grade 3 (good): Some words are illegible but understood by a physician

• Grade 4 (excellent): Legible.

Two independent investigators assigned a single legibility grading after reviewing all four prescriptions written by each student for pre-/post-test. In case of discrepancies between the two investigators, consensus was reached by seeking the opinion of a third investigator.

Statistical analysis

Continuous data were summarized as mean (standard deviation) or median (interquartile range). Categorical data were summarized as frequency (percentage). The median pre-test and post-test scores were compared using the Wilcoxon signed-ranks test. The frequency of correct responses and number of interns for each grade of prescription legibility between the pre-test and the post-test were compared using McNemar’s Chi-square test. Data analysis was conducted using the Statistical Package for Social Sciences (SPSS) version 24. P <0.05 was considered statistically significant. Manual content analysis was conducted by the first and second authors for the feedback obtained from medical interns.

Results

Of 120 interns, 77 attended the training program with 25, 26, and 26 interns attending each day, respectively. Of those 77 interns, 73 provided consent and completed both pre-test and post-test assessments. Their mean (± SD) age in years was 22 (±0.788). There was a slight preponderance of female over male participants [39 (53.4%) vs 34 (46.6%)].

As evidenced from Table 2, the median post-test scores were significantly higher for the questions on the definition of rational drug use, the definition of P-drug, enumerating steps in rational prescribing, and four prescription writing activities. Overall, there was a statistically significant increase in the median (interquartile range) total scores from 52 (44.6 – 60) to 84 (70 – 88) after the training (P = 0.001).

Table 2.

Comparison of pre-test and post-test scores among interns (n=73)

Questions/activity	Maximum possible score	Median (IQR)		P (Wilcoxon signed-ranks test)
		Pre-test	Post-test
Definition of rational drug use	4	0	2 (1–2)	0.001*
Definition of P-drug	3	0	1 (0–2)	0.001*
Steps in rational prescribing	6	0	6 (5–6)	<0.001*
Four prescription writing score
Superscription	40	18 (13.7-20)	36 (30-38)	0.001*
Inscription	32	14 (12.5-16)	29 (27-32)
Subscription	8	4 (0-5)	7 (4-8)
Total	80	44 (26.5–52)	74 (56–78)
Overall score	93	52 (44.6–60)	84 (70–88)	0.001*

*P<0.05 is considered significant

As shown in Table 3, we also assessed students’ performance in the pre-test and post-test, concerning each question and each subdivision in questions. Compared to pre-test, there was a statistically significant increase in the percentage of correct responses for all questions in the post-test. Before the training, except for a few interns, none of them knew about rational drug use, P-drug concept, or steps in rational prescribing. After the training program, nearly half of the interns (43.8 – 56.2%) were aware that rational use of a drug means the use of the appropriate drug in the right dose and for the correct duration. However, only 27.4% understood that the drug must be available at a reasonable cost to the patients for the drug use to be considered rationale. The educational intervention helped about 53.4% of interns understand the definition of P-drug, and more than 75% of them became acquainted with the six steps in rational prescribing. Moreover, the training has tremendously improved their prescription writing skills. In the post-test, all the interns correctly mentioned the patient’s name, age and gender, written drug names in generic, and written instructions to the patient. Also, more than 90% of them have written the date, patient address, prescribers’ details (name, registration number, address, and signature), diagnosis, drug formulation, route of administration, drug dose, frequency, and duration of administration in the post-test. In addition, 79.4% and 67.1% of the interns chose the right drug for the condition and wrote the drug name in capital letters in the post-test.

Table 3.

Comparison of frequency of correct responses between pre-test and post-test among interns (n=73)

Question/items	Frequency (%) of correct response		P (McNemar’s Chi-square test)
	Pre-test	Post-test
Definition of rational drug use
Appropriate drug	1 (1.4)	33 (45.2)	0.001*
Appropriate dose	3 (4.1)	41 (56.2)
Appropriate duration	1 (1.4)	32 (43.8)
Appropriate cost	1 (1.4)	20 (27.4)
Definition of P-drug	1 (1.4)	39 (53.4)	0.001*
Steps in rational prescribing
Step 1	1 (1.4)	61 (83.6)	<0.001*
Step 2	0	63 (86.3)
Step 3	0	63 (86.3)
Step 4	1 (1.4)	67 (91.8)
Step 5	1 (1.4)	64 (87.7)
Step 6	0	58 (79.5)
Four prescription writing score
Superscription
Date	32 (43.8)	70 (96)	0.001*
Prescriber name	13 (17.8)	71 (97.2)
Prescriber registration number	12 (16.4)	70 (96)
Prescriber address	12 (16.4)	70 (96)
Patient name	65 (89)	73 (100)
Patient age	67 (91.8)	73 (100)
Patient gender	67 (91.8)	73 (100)
Patient address	23 (31.5)	68 (93.1)
Diagnosis	40 (54.7)	71 (97.2)
Symbol Rx	42 (57.5)	70 (96)
Inscription
Choosing correct drug	23 (31.5)	58 (79.4)
Drug formulation	34 (46.5)	69 (94.5)
Route of administration	58 (79.5)	71 (97.2)
Drug name in capitals	28 (38.3)	49 (67.1)
Drug name in generic	67 (91.8)	73 (100)
Drug dose	24 (32.8)	67 (91.8)
Frequency of administration	29 (39.7)	70 (96)
Duration of administration	51 (70)	71 (97.2)
Subscription
Instructions to patient	48 (65.7)	73 (100)
Question/items	10 (13.6)	68 (93.1)	0.001*

*P<0.05 is considered significant

Figure 2 shows that of the total 73 interns, a significantly greater number of them wrote legible prescriptions (grade 4/excellent – 44 in pre-test vs 52 in post-test; P = 0.001) after the training.

Figure 2.

Legibility scoring of the prescriptions written by interns (n = 73). McNemar’s Chi-square test was used for analysis; *P < 0.05 is considered significant

The feedback provided by the interns on the training program was largely positive, with scope for improvement, as shown in Table 4. The interns perceived the sessions as interactive and informative, and the group discussions as thought-provoking and useful. They appreciated the friendly attitude of the facilitators, their ability to explain the concepts clearly and easily, and their resource materials, including PowerPoint presentations. The training helped refresh their prescription writing skills, which they learned in the second year during their pharmacology classes. They also felt that the pre-test and post-test provided insights into the extent of learning and retention. They also gave suggestions for improvement, such as increasing the session duration, incorporating more case scenarios for discussion, and adding interactive sessions with fun-filled activities.

Table 4.

Interns’ feedback on training program: facilitating factors and suggestions for improvement (n=73)

Interns’ feedback	Number (percentage) of interns
Facilitating factors for learning
Group discussions were useful, helpful, and made us think	31 (42.5)
Session was brilliant, interactive, and informative	23 (31.5)
Friendly resource persons	16 (21.9)
Helps to recollect and revise writing prescription learned from pharmacology	14 (19.2)
Concept explained in a clear and easy manner to understand	9 (12.3)
Pre-test and post-test gave clarity and helped to know how much we remembered	6 (8.2)
Resource material and PowerPoint presentation were good	5 (6.8)
Suggestions for improvement of the program
More case scenario and answers for it can be given	10 (13.7)
Fun activity can also be included	5 (6.8)
Duration of the session can be increased	5 (6.8)
More interaction needed and theory part can be reduced	1 (1.4)

Discussion

This study shows that the training program based on the WHO guide to good prescribing significantly improved interns’ knowledge of rational drug use and their rational drug prescribing skills. Overall, after the training, their median test scores increased from 52 to 84, out of a maximum score of 93.

Our results are consistent with similar studies demonstrating the efficacy of short-structured training programs based on WHO’s Good Prescribing Guide, in improvement in rational drug prescribing skills. A study by Venkatesan M et al.[10] in Puducherry, India, showed that a one-day skill-based training program on rational drug treatment for medical interns produced a self-perceived improvement in their skill in rational treatment. Similarly, a study conducted in Turkey by Dikici MF et al.[11] showed that a one-day workshop in rational pharmacotherapy for interns produced a significant improvement in rational prescribing (rationality of drug choice, and prescription format). However, their study showed that the training did not significantly improve prescription legibility, which was in contrast to the findings of our study, in which the training led to a significant increase in the number of interns writing highly legible prescriptions. A similar one-day workshop on writing rational drug prescriptions for interns by Narasimhegowda H et al.[12] in Mysore, India, using case vignettes, improved their rational prescription writing skills.

Our study shows that except for a few, the majority of our interns were unaware of the definition of rational drug use, the P-drug concept, or the WHO six steps of rational prescribing, and also, many of them failed to write several essential elements in the prescriptions, before the training. Similar alarming observations of poor knowledge of rational drug use and rational drug prescribing skills among interns were observed by other researchers worldwide.[5,6,7,8,12] Thus, despite training medical students on rational drug use during their second year as a part of the pharmacology curriculum, knowledge retention in internship remains bleak. Reduced retention of rational drug use training given for medical students in the earlier years of education compared to the later years was also observed in a study by Bebitoglu BT et al.[13] Thus, there is an urgent need to train interns on rational drug use to optimize patient outcomes, promote drug safety, and reduce healthcare-related costs.

We structured the rational drug prescribing training program for a condensed time frame, enabling it to be included as part of their routine training programs. A study by Kathrotia R et al.[14] showed that they included rational drug use training as one of the components of intern orientation program and that it was effective.

In this study, we used learner-centric methods, such as interactive lectures and small group discussions, on case scenario-based tasks on choosing a P-drug and verifying its suitability, mock prescription writing, and giving instructions/warnings to patients. Although our study revealed that the training was successful and well-perceived, knowledge gap still exists and not all interns learned the skill of rational drug prescribing. Thus, it is essential to supplement the learning process and make it more fun-filled with the incorporation of various other innovative teaching-learning methods. This will aid in engaging all the learners and provide a memorable learning experience, paving the way for better grasping and retention of knowledge and skills. Literature search revealed that researchers worldwide have attempted various innovative approaches that aid students in delving deeper into the material and applying it effectively in real-life situations. Patient-based learning (patient encounters), pharmacist-led education, the use of case vignettes, critique of doctor-patient communication and prescription video footage, and project-based learning (assessment of outpatient and inpatient prescriptions on rational drug therapy) were the strategies employed to train medical students and interns.[12,15,16,17,18]

Strengths

The strengths of our study include the use of standardized WHO tool for training on rational drug prescribing, short duration of the training program with structured contents, and use of learner-centric teaching methods, such as small group discussion with hands-on case scenario-based activity.

Limitations

The study has several limitations, including a small sample size and being restricted to a single medical college, thus compromising on the generalizability of the findings. Moreover, the study did not assess the change in real-world prescribing practices by interns after training.

There is a need for further exploration of the impact of innovative teaching-learning methods on rational drug use in large-scale multi-centric studies. Additionally, it is necessary to investigate the long-term retention of acquired knowledge and skills, as well as their application in real-time.

Conclusion

Our results suggest that the short-structured learner-centric training program based on the WHO guide to good prescribing significantly improved the knowledge of rational drug use and rational drug prescribing skills among medical interns.

The key messages are medical students need additional training during internship as they often lack the necessary knowledge and skills in rational drug use and prescribing. The WHO guide to good prescribing is a useful tool to train medical interns in rational drug prescribing. Short-structured learner-centric training programs are effective in improving interns’ rational drug prescribing practices. Including such training programs on rational drug prescribing as a part of interns’ orientation program at the beginning of their internship is highly recommended.

Authors’ contribution

NA, RM, KG, and SM were involved in the conception and design of the study. NA and RM performed data acquisition, analysis and interpretation, and prepared the first draft of the manuscript. KG and SM helped in data interpretation and critically revised the manuscript. All authors read and approve the final manuscript and agree to be accountable for all the aspects of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.