The separation of the acquisition and testing of knowledge from competence is, to some extent, an artificial one, yet there is increasing stress on the assessment of competence — the fitness to practice to an expected standard — in medicine. In therapeutics, there are many admirable text books, supplemented by journal articles on drugs, usually organized along the lines of their pharmacology, indications, dosing regimens, pharmacokinetics, adverse reactions and interactions. Such descriptions are frequently supplemented by guidelines or treatment hierarchies to help the reader understand how an individual drug might fit into a management scheme. Competence in practical prescribing is acquired through a mixture of training by, and apprenticeship with, an experienced and more competent individual, by trial and error and by supplementing learning from textbooks and journals, and increasingly, from electronic sources. What ‘Graduate Therapeutics’ claims to do is ‘provide doctors seeking to improve their competence in prescribing by complementing on-the-job training’. It thus seeks to fill a gap between factual learning and practical prescribing through distance learning material with which (to quote the prefix) the reader is invited ‘to engage’. The book is subtitled ‘A Primer for MRCP and Specialist Training’ and whilst keen undergraduates might turn to it to supplement knowledge-based texts, the book is really for postgraduates.
The book is divided into 23 chapters, each dealing with a major therapeutic area. Most chapters concern specific clinical conditions — heart failure, osteoporosis, asthma — but four deal with drug treatment in the elderly, adverse drug reactions, drug interactions and drug overdosage. Each chapter has the same layout: objectives (what the reader will be able to do at the end of the chapter) clinical scenario, a series of questions with spaces for answers, model answers, further questions or continuation of the scenario in which more data are revealed, a bibliography and multiple choice questions. The answers are at the back of the book.
The textural questions are of two kinds; those directly related to the clinical scenario and those that explore a line of thinking based on a previous answer. For example, in the drug interactions chapter, specific drugs are discussed in the clinical setting and then further questions are asked about the mechanisms of drug interactions.
The success of this approach to learning is determined by three factors, two dependent on the skills ofthe author and the third on the reader. As the preface says, the reader must ‘engage’ with each step of the Q & A section as the scenarios unfold. He must be willing to lay bare his knowledge at the start and try to build on it to complete the section. The author's tasks are to challenge the reader's basic knowledge through the management of the clinical scenario and then to ask relevant and related questions that take him to new areas that, when mastered, would give greater confidence in the future management of patients. The multiple choice questions should reiterate on earlier material and consolidate on the knowledge gained.
In all these respects, this book succeeds admirably. Should the reader know the subject well, he can go straight to the multiple choice questions. Questions in the text are often phrased in a companionable way, e.g. ‘jot down what you know about ...’ ‘can you remember how ...’. The case histories are realistic and deal with important topics. A small point of layout that could be improved is that the gap between a question and the answer space is small and the eye is tempted down to the answer. A computerized system would clearly avoid this, but in the textbook it would require separating questions and answers completely and could spoil the flow of the work.
The book costs £35 and is excellent value. It deserves to be widely used. It will require regular updating as therapeutics and use of drugs through guideline management is changing rapidly. There are also other areas of medicine that lend themselves to this approach for learning to gain competence in clinical management.