Safe prescribing by junior doctors

Tobaiqy et al. in a recent study have reported that Foundation Year 1 (FY 1) doctors lack confidence in prescribing several groups of drugs [1]. The majority of the FY 1 doctors felt that undergraduate education in clinical pharmacology and therapeutics (CPT) had not prepared them adequately for prescribing duties.

CPT of drugs that are commonly prescribed across specialties, e.g. analgesics, anti-inflammatories, antacids, antibiotics, antihypertensives and anticoagulant drugs, should be adequately taught to medical students because they are likely to be encountered on a doctor's first day on the ward after graduation. However, it is not possible to teach the whole formulary in depth to medical students, and drugs that are more specific to certain specialties are probably best taught during specialty postings. Moreover, there are considerable differences in local formularies between NHS hospital trusts in the UK. This poses a challenge in terms of what drugs should be taught and in how much detail, as students may move to a new region for FY training following graduation.

Confidence in prescribing comes from practice and familiarity with a particular drug on the ward. CPT is taught in most medical school curricula, but students have difficulty translating the theory into practice until they are faced with the responsibility of making prescribing decisions [2, 3]. Even though medical students may be taught to write prescriptions which are countersigned by a doctor, confidence only comes with practice, responsibility and adequate supervision.

Aronson [4] has rightly noted that the writing of the prescription is a late event in the prescribing process and describes four preceding steps: (i) making an accurate diagnosis, (ii) assessing the balance of benefit to harm, (iii) choosing the right drug among a range of alternatives and the right dose regimen, and (iv) discussion with the patient about the proposed treatment and potential beneficial and adverse effects. It would be difficult to teach medical students all of these steps for all the drugs in the formulary and it is not time efficient to attempt to do so.

More focus should be placed on teaching the principles of writing a proper prescription, which applies to any drug being prescribed. This is relevant to medical students as well as practising doctors, and should be a core part of continuous professional development programmes. Many doctors who are able to prescribe drugs confidently are unfortunately unable actually to write clear legible prescriptions that can be dispensed or administered without confusion [5, 6].

These findings are in keeping with unpublished audits done by the authors in two District General Hospitals in the north and south of England. A snap-shot of prescribing practices in the orthopaedic directorate of both hospitals was done at the beginning of the audit cycle. The percentage of inpatient prescription charts with errors in both hospitals was 54% and 60%, respectively. Most of the drugs were analgesics, anti-inflammatory drugs and antibiotics. There were no FY 1 doctors working in either of the units, so all the prescriptions had been done by doctors who had been prescribing for >1 year. The doctors frequently did not know the local prescribing guidelines or how to obtain them.

We think that these audits suggest that prescription writing is poor even among doctors who are confident about the CPT of the prescribed drugs, and that knowing what drug to prescribe to which patient does not necessarily translate to a good prescription. Various reasons have been identified for doctors writing wrong prescriptions [7], but it is an issue that needs to be addressed continuously throughout a doctor's professional career. We do not believe all drug-prescribing issues can be adequately and sufficiently addressed during undergraduate medical training.