Table 2.

Articles (n = 47) evaluating the prescribing competencies of final‐year medical students

Author	Setting	Study design	Participants	CPT topic	Methods	Main results	Kirkpatrick level c	MERSQI‐score a
Abbo et al. (2013) 23	USA; 3 medical schools	Single‐group, cross‐sectional descriptive	317 final‐year (4th) medical students	Antimicrobial prescribing and resistance	24‐point self‐administered electronic survey instrument about perceptions, knowledge and attitudes to antimicrobial use and resistance, including 11 clinical vignettes	92% agreed that knowledge of antimicrobials is important. Mean correct knowledge score was low (51%; max. 100%). Only one‐third perceived their preparedness to be adequate in some fundamental principles of antimicrobial use. 90% wanted more education on appropriate use of antimicrobials	1, 2b	12
Abubakar et al. (2015) 30	Malaysia: one medical school	Multiple groups, cross‐sectional descriptive	37 penultimate‐(4th) year and 50 final‐year (5th) medical students	Pharmacovigilance	25‐point self‐administered written questionnaire about knowledge, attitudes and practices regarding ADRs and pharmacovigilance	78% agreed that ADR reporting is a professional obligation. 59% recognized the right functions of pharmacovigilance. Only 21% knew the method used to report ADRs; 47% had never received any training in how to report ADRs	1, 2b	11
Agrawal et al. (2013) 31	India; one university	Multiple groups, cross‐sectional descriptive	102 2nd‐year and 98 final‐year (5th) medical and dental students	Contraception	55‐point self‐administered written questionnaire about knowledge, attitudes, and barriers to practice regarding oral contraceptive pills	Average knowledge score was low (16.7; max. 30); final‐year students had higher knowledge scores compared with 2nd year students. Most students had negative perceptions and attitudes to oral conceptive pills	2b	8.5
Al‐Wadaani (2013) 87	Saudi Arabia; one medical school	Single‐group, cross‐sectional descriptive	73 final‐year (6th) medical students	Cardiovascular	22‐point self‐administered written questionnaire about knowledge, attitudes and practices regarding diabetes and diabetic retinopathy	Overall knowledge, attitude and practice scores were moderate (64.8; max. 100). Students lacked knowledge about the follow‐up of diabetic patients for the screening of diabetic retinopathy. 90% of students did not know the proper angle of insulin injection	2b	10.5
Awad et al. (2012) 32	Kuwait; one university	Multiple groups, cross‐sectional descriptive	54 junior and 68 senior (4th–7th‐year) medical and pharmacy students	Complementary and alternative medicines	Self‐administered written questionnaire about knowledge, perceived effectiveness and barriers to complementary and alternative medicine	Medical students had poor knowledge of complementary and alternative medicine. Over two‐thirds had positive attitudes. Lack of trained professionals and lack of scientific evidence were the most common perceived barriers	2b	9
Azeem et al. (2010) 80	Pakistan; one university hospital	Single‐group, cross‐sectional descriptive	105 medical graduates	General prescribing	Self‐administered written questionnaire about perceptions regarding preparation and competency to prescribe as junior doctors	19% considered themselves competent to prescribe at the time of graduation. <35% felt comfortable in providing information about treatment options to patients. The majority (59–95%) indicated a lack of formal teaching and practice at skills relating to drug therapy	1, 2a	6.5
Beyhun et al. (2016) 85	Turkey; one medical school	Single‐group, cross‐sectional descriptive	148 final‐year (6th) medical students	Narcotics	Self‐administered written questionnaire about awareness of synthetic cannabinoids	Students’ mean awareness score was moderate (4.7; max. 9). Students lacked awareness of usage, illegal status and clinical effects of synthetic cannabinoids	2b	8.5
Brinkman et al. (2017) 10	Europe; 17 medical schools from 15 countries	Single‐group, cross‐sectional descriptive	895 final‐year (5th–6th) medical students	General prescribing	Online assessment of prescribing knowledge (24 MCQs) and skills (5 patient cases). Self‐administered questionnaire about self‐reported confidence, perceived preparedness for prescribing, and received CPT education	Overall knowledge score was moderate (70%, max. 100%). 46% of the therapies were inappropriate and 55% of the prescriptions contained an error. Students lacked confidence in essential prescribing skills and felt not adequately prepared for prescribing responsibilities. >60% were not satisfied with the quantity and quality of undergraduate CPT education	1, 2b	13.5
Brinkman et al. (2014) 27	The Netherlands; one medical school	Single‐group; cross‐sectional descriptive	483 final‐year (6th) medical students	General prescribing	Prescribing performance during 4 therapeutic consultations with real patients during clinical clerkship, self‐administered online questionnaire on self‐reported confidence in prescribing	Adequate performance score (7.93; max. 10). Majority (66–88%) lacked self‐reported confidence in essential prescribing skills	2a, 3	9
Cheng & Yu (2012) 33	China; one medical school	Multiple groups; cross‐sectional descriptive	103 penultimate‐year (6th) and 80 final‐year (7th) medical students, 59 clinical master degree candidates, 50 clinical doctors	Narcotics	45‐point self‐administered written questionnaire about knowledge of cancer pain management	Senior medical students had a poor knowledge of cancer pain management, especially among non‐oncological medical students	2b	11.5
Chuenchom et al. (2016) 76	Thailand; three medical schools	Single‐group; cross‐sectional descriptive	455 final‐year (6th) medical students	Antimicrobial prescribing and resistance	Self‐administered written questionnaire about perception, attitude and knowledge of antimicrobial resistance, appropriate antimicrobial use and infection control	Mean knowledge scores were low (1.61; max. 5). Nearly all participants had a positive attitude about antimicrobial resistance. >10% reported that they had never learned about antimicrobial resistance and appropriate antibiotic use. Nearly all students wanted more education about rational antimicrobial use	1, 2b	10
Coombes et al. (2008) 81	Australia; two teaching hospitals	Single‐group; cross‐sectional descriptive	101 final‐year (4th) medical students	General prescribing	21‐point self‐administered written questionnaire about students' perceptions of their readiness to prescribe, associated risks and outcome if involved in an error, as well as their perceptions of available support	84% felt able to prescribe for simple complaints, whereas only 54% felt comfortable to prescribe warfarin and 66%to prescribe IV fluids. 99% were under the misapprehension that potentially harmful prescriptions would be safely administered. 79% perceived that they would be blamed if they made a prescribing error	2a	8.5
Dyar et al. (2013) 35	France; one medical school	Multiple groups; cross‐sectional descriptive	34 penultimate‐year (5th) and 26 final‐year (6th) medical students	Antimicrobial prescribing and resistance	41‐point self‐administered online questionnaire about knowledge, perceptions and beliefs about antibiotic resistance and prescribing	Final‐year students were highly aware of and concerned about the overuse of antibiotics. Areas of non‐confidence and gaps in knowledge were found. Students consistently overestimated the current burden of resistant bacteria and were unaware of success in reducing MRSA infections. 79% wanted more training in antibiotic selection	1, 2b	9.5
Dyar et al. (2014) 77	Europe; seven medical schools from seven countries	Single‐group; cross‐sectional descriptive	338 final‐year (5th–6th) medical students	Antimicrobial prescribing and resistance	41‐point self‐administered online questionnaire about knowledge, perceptions and beliefs about antibiotic resistance and prescribing	Students lacked confidence in combination therapy and dose selection of antibiotics. Students consistently overestimated the current burden of resistant bacteria and were unaware of success in reducing MRSA infections. 74% wanted more training in antibiotic selection	1, 2b	10.5
Dyasanoor & Urooge (2016) 28	India; one university hospital	Multiple groups; cross‐sectional descriptive	52 undergraduates, 221 internsa, 227 postgraduates	General prescribing	Quality of 500 prescriptions dispensed by participants analysed according to 19 parameters	39% of the prescriptions by interns were not adequate because important parameters were missing. Prescriptions written by undergraduates were better than those written by interns and postgraduates	3	10
Grossman & Sheidler (1985) 25	USA; one university hospital	Multiple groups; pretest intervention	4 2nd‐year, 12 penultimate‐year (3rd), 1 final‐year (4th) medical student, 68 house officers	Narcotics	3 clinical vignettes about converting narcotic analgesic regimen in patients with pain	2% of the answers of medical students were within the correct range. There were no significant differences between the responses among individuals at different education levels	2b	10
Gyawali et al. (2016) 46	Nepal; one university hospital	Multiple groups; cross‐sectional descriptive	120 final‐year (5th) medical students, 117 internsa	Generic prescribing and substitution	Self‐administered written questionnaire about knowledge and perceptions of generic medicine and generic prescribing	Only 5% knew the correct regulatory limits for bioequivalence. 46% had the impression that brand‐name medicines were required to meet higher safety standards than were generic medicines. 17% had the impression that generic medicines caused more side effects and were less effective than brand‐name medicines	2b	12.5
Haque et al. (2016) 36	Malaysia; one medical school	Multiple groups; cross‐sectional descriptive	41 3rd‐year, 55 penultimate‐year (4th) and 45 final‐year (5th) medical students	Antimicrobial prescribing and resistance	21‐point self‐administered written questionnaire about knowledge, beliefs and practices regarding antibiotic resistance and prescribing	>50% of final‐year students lacked confidence in combination therapy and dose and duration selection of antibiotics. Students consistently overestimated the current burden of resistant bacteria. 88% wanted more training in rational antibiotic selection	1, 2b	12.5
Harakeh et al. (2015) 37	Saudi Arabia; two medical schools	Multiple groups; cross‐sectional descriptive	1042 1st‐year to final‐year (6th) medical students	Antimicrobial prescribing and resistance	20‐point self‐administered written questionnaire about knowledge, attitudes and practices regarding the use of antibiotics for upper respiratory tract infections	93% of the final‐year medical students had adequate knowledge of antibiotic effectiveness. Similarly, most were aware of antibiotic abuse and development of drug resistance in bacteria	2b	9.5
Hassali et al. (2007) 51	Australia; 10 universities	Multiple groups; cross‐sectional descriptive	400 final‐year (5th) medical students and 289 final‐year (5th) pharmacy pre‐registrants	Generic prescribing and substitution	20‐point self‐administered online questionnaire about knowledge and perceptions of generic medicine, generic prescribing and generic substitution	Both groups scored poorly on the allowable bioequivalence limits, with pharmacy pre‐registrants scoring better. Both groups incorrectly believed that generic medicines met lower safety standards, were inferior in quality, less effective and produced more side effects than brand‐name medicines	2b	11.5
Heaton et al. (2008) 82	UK; 25 medical schools	Multiple groups; cross‐sectional descriptive	2413 medical students graduating in 2006–2008	General prescribing	17‐point self‐administered online questionnaire about undergraduate training and assessment in pharmacology and therapeutics, the acquisition of prescribing skills and self‐reported confidence in prescribing	Only 38% felt confident about prescription writing and 35% had filled in a hospital prescription chart more than three times during training. 74% felt that there was (far) too little teaching and 56% disagreed that their assessment thoroughly tested knowledge and skills	1, 2a	10
Hema et al. (2012) 47	India; one university hospital	Multiple groups; cross‐sectional descriptive	80 final‐year (5th) medical students, 88 internsb and 132 postgraduates	Pharmacovigilance	25‐point self‐administered written questionnaire about awareness, knowledge and methods to apply pharmacovigilance	Compared with interns and postgraduates, final‐year students had a lower awareness score (2.5; max. 5), lower knowledge score (2.3; max. 8) and lower method of application score (5.8; max. 12)	2b	10
Holstein et al. (2000) 38	Germany; 21 academic teaching and university hospitals	Single‐group; cross‐sectional descriptive	310 final‐year (6th) medical students	Cardiovascular	20‐point self‐administered written questionnaire about clinically relevant diabetes treatment knowledge and experience	Marked gaps in manual experience and clinically relevant knowledge of diabetes, particularly in practical aspects of diabetes therapy. 45% had never injected insulin and 68% had no experience with the insulin pen. 81% were not satisfied with the diabetes teaching	1, 2b	10.5
Hoque et al. (2016) 39	Bangladesh; one medical school	Multiple groups; cross‐sectional descriptive	40 3rd‐year, 33 penultimate‐year (4th) and 34 final‐year (5th) medical students	Antimicrobial prescribing and resistance	21‐point self‐administered written questionnaire about knowledge, attitudes and perceptions about antimicrobial resistance and rational use of antimicrobials	Participants had an average level of confidence in the rational use of antimicrobials, with final‐year students being more confident than earlier‐year students. Students underestimated the prevalence rate of MRSA infection. 94% wanted more training in antibiotic selection	1, 2b	11.5
Huang et al. (2013) 40	China; three teaching hospitals	Multiple groups; cross‐sectional descriptive	1236 medical students, including 241 final‐year (5th year) students, 852 nonmedical students	Antimicrobial prescribing and resistance	30‐point self‐administered online questionnaire about knowledge, attitudes and perceptions about antibiotic use	Senior students had more knowledge of and positive attitudes to antibiotic use compared with junior students. No difference between penultimate‐year (4th) and final‐year (5th) students was observed. There was more excessive use of antibiotics among senior medical students	2b	12.5
Humphreys et al. (2006) 78	Ireland; three medical schools	Single‐group; cross‐sectional descriptive	108 medical graduates	Antimicrobial prescribing and resistance	19‐point self‐administered written questionnaire about knowledge and understanding of treatment and prevention of common infections	±60% of the questions were answered correctly; questions regarding the rational use of antibiotics were poorly answered compared with other questions	2b	9
Ibia et al. (2005) 24	USA; 21 medical schools	Multiple groups; cross‐sectional descriptive	30 penultimate‐year (3th) and 959 final‐year (4th) medical students	Antimicrobial prescribing and resistance	Six paediatric vignettes regarding clinical management of different upper respiratory tract infections	99% were informed about the problems of antibiotic resistance. Majority of students 30–56%) prescribed antibiotics inappropriately for viral upper respiratory diseases. No subanalysis for done for study year	2b	11.5
Iffat et al. (2014) 41	Pakistan; multiple universities	Multiple groups; cross‐sectional descriptive	78 3rd‐year, 212 penultimate‐year (4th) and 241 final‐year (5th) dental and medical students	Pharmacovigilance	31‐point self‐administered written questionnaire about knowledge, attitudes and perceptions about ADR reporting	88% had knowledge of ADRs. Medical students showed generally positive attitudes to ADR reporting. 55% did not know the definition of pharmacovigilance. Only 10% knew where to report ADRs. 72% indicated that they had not received any training in reporting ADRs	2b	12.5
Ismail et al. (2015) 83	Malaysia; one medical school	Single‐group; cross‐sectional descriptive	23 final‐year (5th) medical students	Pharmacovigilance	Self‐administered written questionnaire about knowledge, attitudes and practice regarding ADRs and pharmacovigilance	96% knew the term ADRs. 57% did not know the method for reporting ADRs, although 78% had observed ADRs during clinical clerkships. 87% had not received any training in ADR reporting during their medical training	1, 2b	10
Jamshed et al. (2014) 52	Malaysia; one medical school	Multiple groups; cross‐sectional descriptive	72 final‐year (5th) medical students and 51 final‐year (5th) pharmacy students	Antimicrobial prescribing and resistance	Self‐administered written questionnaire about understanding of antibiotic use and antibiotic resistance	94% showed adequate knowledge regarding the course content related to antibiotics. Only 30% were able to recognize penicillin and vancomycin‐resistant bacteria. Pharmacy students had better knowledge than medical students	2b	11
Kaki (2011) 86	Saudi Arabia; one medical school	Single‐group; cross‐sectional descriptive	325 final‐year (6th) medical students	Narcotics	18‐point self‐administered written questionnaire about knowledge, beliefs and attitudes to cancer pain management	46% considered cancer pain as untreatable. 59% considered that the risk of addiction is high with opioid prescriptions. 68% limited opioid prescriptions to patients with poor prognosis. 63% indicated that they had received no education in pain medicine during their medical training	1, 2b	12
Khan et al. (2013) 42	India; one medical school	Multiple groups; cross‐sectional descriptive	148 3rd‐year medical students and 130 medical graduates	General prescribing	Self‐administered written questionnaire about knowledge, attitudes and behaviour regarding safe prescribing, including one patient case	The knowledge and attitudes of medical graduates were satisfactory. 12% prescribed unnecessary antibiotics. Prescribing skills were generally inadequate as errors in written prescriptions were commonly found	2b	10.5
Meher et al. (2015) 43	India; one medical school	Single‐group; cross‐sectional descriptive	60 2nd‐year, 60 penultimate‐year (4th), 60 final‐year (5th) medical students	Pharmacovigilance	21‐point self‐administered written questionnaire about knowledge, attitudes and practice of pharmacovigilance	Mean knowledge and attitude scores for final‐year students were low (4.3; max. 7 and 1.7; max. 4, respectively). Penultimate‐year students had better knowledge and attitude scores than final and 2nd‐year students	2b	9.5
Olakunle et al. (2014) 79	Nigeria; three medical schools	Single‐group; cross‐sectional descriptive	241 final‐year (6th) medical students	Antimicrobial prescribing and resistance	Self‐administered written questionnaire about knowledge of diagnosis and management of tuberculosis under DOTS	Only 46% correctly mentioned the various categories of the DOTS treatment regimen. 7% were able to identify the correct treatment duration for new tuberculosis	2b	10.5
Oshikoya et al. (2008) 21	Nigeria; one medical school	Single‐group; cross‐sectional descriptive	34 final‐year (6th) medical students	General prescribing	Self‐administered written questionnaire about knowledge of principles of good prescribing and prescribing skills, including two clinical cases	92% knew that rational prescribing involved prescribing correct dosage of an appropriate medicine formulation. Less than 50% of the prescriptions included name, case file number, age and gender of the patient	2b	10.5
Ozoh et al. (2014) 89	Nigeria; one medical school	Single‐group; cross‐sectional descriptive	139 final‐year (6th) medical students	COPD	Self‐administered written questionnaire about knowledge of COPD diagnosis and treatment	38% had good, 37% fair and 20% poor knowledge of COPD management. 55% were familiar with the GOLD guidelines. 28% correctly identified inhaled steroids and bronchodilators as therapy for stable COPD	2b	9.5
Puchner & Zacharisen (2002) 48	USA; two academic and two teaching hospitals	Multiple groups; cross‐sectional descriptive	36 medical students (junior/senior), 342 medical specialists	Antimicrobial prescribing and resistance	Self‐administered written questionnaire about cephalosporin prescribing and knowledge of penicillin allergy	There was marked variation between study groups in the prescribing of cephalosporin and requesting penicillin skin testing. In general, medical specialists had a better knowledge of penicillin allergy than medical students	2b	8.5
Rehman et al. (2011) 88	USA; one medical school and four teaching hospitals	Multiple groups; cross‐sectional descriptive	121 final‐year (4th) year medical students, 354 junior doctors	Cardiovascular	11‐point self‐administered written questionnaire about knowledge of hypertension diagnosis and management	Only 8% answered the questions regarding hypertension treatment correctly. Mean number of correct answers given by final‐year students was low (5.2; max. 11), although they did better than junior doctors	2b	12.5
Rothwell et al. (2012) 29	UK; three medical schools	Single‐group; cross‐sectional descriptive	65 medical graduates	General prescribing	Multiple methods, including face‐to‐face and telephone interviews, questionnaires and secondary data from prescribing safety assessment	73–80% of the graduates felt generally underprepared for prescribing. Only 16–19% of the graduates passed the prescribing safety assessment at the first attempt	2b	11
Scaioli et al. (2015) 44	Italy; one medical school	Multiple groups; cross‐sectional descriptive	465 1st year, 187 2nd‐year, 190 3rd‐year, 70 4th‐year, 79 penultimate‐year (5th), 59 final‐year (6th) healthcare students	Antimicrobial prescribing and resistance	31‐point self‐administered written questionnaire about knowledge and attitude about antibiotic usage and antibiotic resistance	More than 90% answered all items correctly. However, 20% were not aware that antimicrobial drugs were not effective against viruses and that these drugs can cause secondary infections. However, no subanalysis by study year was performed	2b	11.5
Schutte et al. (2017) 45	The Netherlands; eight medical schools	Multiple groups; cross‐sectional descriptive	354 3rd‐year, 92 4th‐year, 106 penultimate‐year (5th), 298 final‐year (6th) medical students	Pharmacovigilance	10‐point self‐administered online questionnaire about pharmacovigilance awareness, skills and knowledge	Final‐year students had marginally better knowledge scores than 3rd‐year students (68% vs. 64%). Only 48% of the final‐year students felt sufficiently prepared to report ADRs in future practice, and a substantial proportion did not know the authority to which they should report ADRs	1, 2b	12.5
Sharrad & Hassali (2011) 84	Iraq; six medical schools	Single‐group; cross‐sectional descriptive	546 final‐year (6th) medical students	Generic prescribing and substitution	23‐point self‐administered written questionnaire about perception and knowledge of generic medicines and generic prescribing	>70% of the respondents did not possess sufficient knowledge about bioequivalence limits for generic medicines. >60% of the students thought that generic medicines were inferior, less effective and produced more side effects than brand‐name medicines	2b	13
Thriemer et al. (2013) 49	Democratic Republic of Congo; one medical school and multiple hospitals	Multiple groups; cross‐sectional descriptive	106 final‐year (6th) medical students and 78 medical doctors	Antimicrobial prescribing and resistance	23‐point self‐administered written questionnaire about knowledge, attitudes and practices regarding antibiotic prescribing	Mean knowledge scores were generally low (4.9; max. 9) and did not differ significantly between the groups. Students had high self‐confidence in antibiotic prescribing (86%), although this was lower than that of qualified doctors (95%)	2b	12.5
Upadhyaya et al. (2012) 22	India; one teaching hospital	Single‐group; cross‐sectional descriptive	50 medical graduates	General prescribing	22‐point self‐administered written questionnaire about self‐rated knowledge of the principles of good prescribing	48% rated their prescribing knowledge as average, and 18% as (very) poor. 58% felt that their medical training did not prepare them for rational prescribing. 42% felt that they had some problems with writing a prescription during their internship	1, 2a	7
Weber et al. (1986) 50	Canada; one paediatric hospital	Multiple groups; cross‐sectional descriptive	28 final‐year (4th) medical students, 21 paediatric residents, 22 paediatricians	General prescribing	Six paediatric patient cases about knowledge of the price of frequently prescribed medications	Students' estimations were adequate in 40% of the cases, which was lower than that of paediatric residents (52%) and paediatricians (62%)	2b	8
Weinstein et al. (2000) 34	USA; one medical school	Multiple groups; cross‐sectional descriptive	88 1st‐year medical students, 180 final‐year (4th) medical students	Narcotics	49‐point self‐administered written questionnaire about knowledge and attitudes on pain and the use of opioid analgesics	Senior medical students scored as well as, or better than, 1st‐year students on questions related to knowledge about pain. However, they had a more negative attitude to relieving chronic pain and seemed to have less understanding about the causes of pain in cancer patients	2b	10.5
Wheeler et al. (2004) 26	UK; one medical school	Multiple groups; cross‐sectional descriptive	87 2nd‐year, 98 penultimate‐year (3rd), 78 final‐year (4th) medical students	General prescribing	Online multiple‐choice examination about dose‐calculating skills	The mean knowledge score for all students was low (1.2; max. 3), although final‐year students had significantly better knowledge scores than 1st‐year students	2b	9.5

ADR, adverse drug reactions; COPD, chronic obstructive pulmonary disease; CPT, clinical pharmacology and therapeutics; DOTS, directly observed treatment, short‐course; GOLD, Global Initiative for Chronic Obstructive Lung Disease; IV, intravenous; MCQ, multiple choice question; MERSQI, Medical Education Research Quality Instrument; MRSA, methicillin‐resistant Staphylococcus aureus

^aThe MERSQI has a minimum score of 5 and a maximum score of 18.

^bInterns in India and Malaysia have graduated from medical school but receive their full registration as a medical doctor after completion of the internship

^cKirkpatrick's four levels of training evaluation are:

Level 1: Participation – covers learners' views on the learning experience, its organization, presentation, content, teaching methods and aspects of the instructional organization, materials and quality of instruction.

Level 2a: Modification of attitudes or perceptions – outcomes here relate to changes in the reciprocal attitudes or perceptions between participant groups towards intervention or simulation.

Level 2b: Modification of knowledge and skills – for knowledge, this relates to the acquisition of concepts, procedures and principles; for skills, this relates to the acquisition of thinking and problem solving, and psychomotor and social skills.

Level 3: Behavioural change – this documents the transfer of learning to the workplace or the willingness of learners to apply new knowledge and skills.

Level 4a: Change in organizational practice – this relates to wider changes in the organization or delivery of care, attributable to an educational programme.

Level 4b: Benefits to patients or clients – this relates to any improvement in the health or well‐being of patients and clients as a direct result of an educational programme.