Abstract
Aims
Prescribing is a core skill for junior doctors, yet 8–10% of their prescriptions contain errors. To ensure adequate training in prescribing, it is important to define the diseases for which junior doctors should be competent to prescribe. The aim of the present study was therefore to identify the essential diseases in prescribing for junior doctors.
Methods
A two‐round Delphi consensus study was conducted among medical specialists, general practitioners, junior doctors, pharmacists and pharmacotherapy teachers from all eight academic hospitals in the Netherlands. Using a five‐point Likert scale, the participants indicated for each item on an initial questionnaire whether it should be considered an essential disease for junior doctors. The items for which ≥80% of all respondents agreed or strongly agreed were accepted as essential diseases.
Results
Sixty‐two participants completed the Delphi survey. In total, 63 of 220 items were considered to be essential diseases.
Conclusion
This is the first Delphi consensus study identifying exact conditions that junior doctors must be able to prescribe for. The essential diseases can be used for training in prescribing and assessment of junior doctors' prescribing competence.
Keywords: medical education, pharmacotherapy, prescribing
What is Already Known about this Subject
Various descriptions of the requirements pharmacotherapy education for undergraduate medical training exist. However, only few studies have identified the specific diseases for which junior doctors should be competent to prescribe.
What this Study Adds
In this study, diseases are identified for which all junior doctors should be competent to prescribe. These essential diseases may shape future pharmacotherapy education and allow rational examination of medical students. Consensus for the essential diseases is obtained in a diverse group of stakeholders.
Introduction
Prescribing is a core skill for junior doctors, who are responsible for a large proportion of all hospital prescriptions. With an expanding therapeutic arsenal and more patients with comorbidity and polypharmacy, good prescribing has become more complex. Studies indicate that 8–10% of prescriptions written by junior doctors contain errors, including fatal prescribing mistakes 1, 2, 3. Moreover, junior doctors report feeling unprepared for their prescribing responsibilities at the time of graduation 4, 5, 6, 7.
Over the years, a number of curricula guidelines for pharmacotherapy curricula education have appeared, ranging from descriptions of only basic principles, to more detailed specifications 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20. The majority of these guidelines provide a list of (general) learning outcomes or competencies, such as: “provide a safe and legal prescription”; “calculate appropriate drug doses and record the outcome accurately”; “a student should become skilled in recognizing common drug interactions”. However, these learning outcomes are not adequate for modern problem‐based learning curricula, which require an exact description of the actual problems that students should be able to solve. That is, the diseases or medical conditions for which junior doctors should be able to competently diagnose and prescribe.
Only two curricula descriptions, both from the UK, provide a detailed list of therapeutic problems for junior doctors 8, 9. These lists were drawn up by experts in the field of (education in) clinical pharmacology, without the use of a formal method to procure consensus. Therefore, the aim of this study was to create a list of essential diseases for which junior doctors should be able to prescribe safely and effectively, based on a Delphi consensus procedure involving various stakeholders.
Methods
Study design
A two‐round Delphi consensus study was conducted between April 2016 and July 2016. The Delphi method is an established scientific means to procure agreement on a given topic 21. A Delphi study typically comprises several sequential survey rounds. In the initial survey round, all participants are asked to judge the items of a questionnaire. In subsequent rounds, they receive a selection of the items again, but this time accompanied by the average score for each item from the previous round. Participants are then asked to re‐evaluate their judgement in the light of the average score of the other participants, thereby moving towards stronger agreement 22, 23, 24.
This study was initiated by the Pharmacotherapy Education Research working group of the Dutch Society for Clinical Pharmacology & Biopharmacy and was approved by the Dutch Association for Medical Education, Ethical Review Report number 577.
Selection of participants
All eight academic hospitals in the Netherlands contributed to this Delphi study. In each centre, a panel of predefined respondents took part, consisting of three teachers in pharmacotherapy (defined as anyone professionally involved in formally organized pharmacotherapy education to undergraduate medical students); five clinical specialists; one pharmacist or clinical pharmacologist; and two recently graduated (<1 year) junior doctors. Participants were anonymous to each other and scored all items without conferring with others.
Materials
A literature review on already existing descriptions of therapeutic problems for which junior doctors must be able to prescribe was performed, yielding two results 8, 9; an additional article was known to the authors 25. All individual items found in at least one of the three articles were combined to form the initial Delphi questionnaire. To ensure the most comprehensive list, the therapeutic problems appearing in the guidelines of the Dutch College of General Practitioners (Nederlands HuisartsenGenootschap) 26 were also included. As this study specifically aimed at the pharmacotherapeutic competence of junior doctors, only diseases for which pharmacotherapy is the primary treatment modality were included. Note that the term disease was interpreted broadly and included pharmacotherapeutic problems such as pain and hypovolaemia. The initial, comprehensive list included 220 items (Appendix S1).
Data collection Round 1
All participants were invited by e‐mail to complete the online Delphi questionnaire, using the web‐based tool SurveyMonkey. A unique code was assigned to each participant to ensure anonymity. Participants were asked to rate the following statement for every item of the questionnaire:
“A junior doctor should be able to safely and effectively prescribe for this therapeutic problem.”
Answers were given on a five‐point Likert scale: 1 = strongly disagree; 2 = disagree; 3 = neither agree, nor disagree; 4 = agree; 5 = strongly agree. Participants were invited to add additional items (diseases or therapeutic problems) that they felt were missing from the provided questionnaire.
In this study, prescribing competence was defined as the capability of a junior doctor to choose, implement and monitor therapy for the given disease – independently and on his/her own responsibility. Consultation with other (more experienced) doctors or specialists should be needed only if the clinical circumstances become more complicated (e.g. patients with extensive comorbidities or polypharmacy) or the initial therapy fails. See Appendix S2 for the full explanation, as given to the participants.
Data analysis Round 1
All items rated 4 (agree) or 5 (strongly agree) by ≥80% of the respondents were immediately accepted as essential diseases. The items rated 4 or 5 by 50–80% of the respondents were reassessed in Round 2. Items with ratings of 4 or 5 by ≤50% of respondents were considered not to be essential problems and discarded. Newly suggested items proceeded to Round 2 as well.
Data collection and analysis Round 2
Round 2 had the same set up as Round 1, but only the items meeting the above criteria were included. For each item, the average score of Round 1 (0.0–5.0) was given, together with the participants' personal rating as given in Round 1. Participants were asked to rate the items once more, in the light of the average score of the other participants (Delphi method). Only the items for which ≥80% of all respondents gave a rating of 4 or 5 were added to the final list of essential diseases.
Results
Sixty‐seven participants from all eight academic hospitals in the Netherlands completed the questionnaire in Round 1, of whom 62 (93%) consequently completed Round 2. As intended, most participants were clinical specialists, from various medical disciplines. Additionally, teachers in prescribing, junior doctors and experts in pharmacology contributed. See Table 1 for demographic information on the participants.
Table 1.
Demographic information of the participants
| Demographic characteristics | Round 1, n = 67 | Round 2, n = 62 |
|---|---|---|
| Age (years) | 41.3 | 40.9 |
| Male | 39 (58%) | 37 (60%) |
| Female | 28 (42%) | 25 (40%) |
| Profession: | ||
| Specialist internal medicine | 21 (31%) | 18 (29%) |
| Specialist surgical medicine | 7 (10%) | 7 (11%) |
| General practitioner | 5 (7%) | 5 (8%) |
| Specialist geriatric medicine | 4 (6%) | 3 (5%) |
| Teacher in pharmacotherapy | 19 (30%) | 19 (31%) |
| Junior doctor | 15 (22%) | 14 (23%) |
| Pharmacist/clinical pharmacologist | 9 (13%) | 8 (13%) |
| Other a | 3 (4%) | 3 (5%) |
| Average years of clinical experience (range) | 15.2 (0–40) | 15.4 (0–40) |
| Average years of teaching experience (range) | 8.5 (0–30) | 8.0 (0–40) |
One neurologist, one insurance doctor, one anaesthesiologist
Of the 220 items on the initial questionnaire, 63 items (29%) were accepted in one of the two rounds. No additional therapeutic problems were suggested by the participants. A summary of the Delphi selection process is presented in Figure 1.
Figure 1.
Flowchart of study items by percentage of participants rating it with a 4 (agree) or 5 (strongly agree), per round
The 63 identified items forming the essential diseases for junior doctors are presented in Table 2 (for the exact scores of every item see Appendix S3).
Table 2.
Final list of essential diseases for junior doctors, total n = 63
| Essential diseases for junior doctors | |||
|---|---|---|---|
| Medical specialty | Therapeutic problem | Medical specialty | Therapeutic problem |
| Internal medicine ( n = 7) | Diabetes mellitus, type 2 | Otorhinolaryngology (n = 7) | Allergic rhinitis |
| Hypoglycaemia | External otitis | ||
| Microcytic anaemia | Acute otitis media | ||
| Deep vein thrombosis | Maxillary sinusitis | ||
| Macrocytic anaemia | Acute tonsillitis | ||
| Hypovolaemia | Acute otitis media in children | ||
| Hypothyroidism | Acute pharyngitis | ||
| Gastroenterology ( n = 8) | Constipation | Neurology (n = 5) | Pain (WHO analgesic ladder) |
| Gastroesophageal reflux disease | Nausea and vomiting | ||
| Acute gastroenteritis | Primary and secondary prevention of stroke | ||
| Peptic ulcers (and eradication of Helicobacter pylori) | Febrile seizure | ||
| Gastritis | Tension‐type headache | ||
| Oropharyngeal candidiasis | |||
| Irritable bowel syndrome | |||
| Haemorrhoids | |||
| Infectious diseases ( n = 3) | Cellulitis and erysipelas | Surgery, urology | Cystitis |
| (bite) wound infection | and gynaecology | Birth control | |
| Chlamydia | (n = 5) | Thromboprophylaxis | |
| Pyelonephritis | |||
| Candida vulvovaginitis | |||
| Cardiology and vascular medicine ( n = 4) | Hypertension in adults | Dermatology and | Conjunctivitis |
| Hypercholesterolaemia | Ophthalmology | Urticaria | |
| Stable angina pectoris | (n = 5) | Chronic eczema (atopic dermatitis) | |
| Atrial fibrillation | Pruritis | ||
| Impetigo (nonbullous) | |||
| Pulmonology ( n = 9) | (bacterial) pneumonia | Psychiatry | Anxiety |
| Coughing | (n = 4) | Panic attack | |
| Asthma attack | Delirium | ||
| Acute rhinosinusitis (the common cold) | Insomnia | ||
| Influenza (and influenza vaccination) | |||
| Acute exacerbation of COPD | |||
| Stable asthma | |||
| Acute bronchitis | |||
| Stable COPD | |||
| Musculoskeletal disorders ( n = 3) | Osteoarthritis | Emergency medicine | Acute anaphylaxis |
| Acute gout | (n = 3) | Drug allergy | |
| Osteoporosis | Insect bite | ||
COPD, chronic obstructive pulmonary disease
Discussion
In this Delphi consensus study, 63 essential diseases were identified. These outcomes provide us with tangible topics upon which modern‐day, problem‐based learning curricula can be shaped. As such, the essential diseases offer a valuable addition to previous, more general, descriptions of learning objectives for pharmacotherapy education 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20. Additionally, the essential diseases may provide rational items for formative and summative examinations. This is particularly relevant, given the different initiatives undertaken to guarantee prescribing competence upon graduation (e.g. the Prescribing Safety Assessment in the UK; Eindtoets Farmacotherapie in the Netherlands).
It is often stated that training in prescribing is best focused around a confined list of core drugs that junior doctors should know how to prescribe 13, 19, 27. The essential diseases might be used to identify these drugs. For all essential diseases, the drugs named in (locally valid) clinical guidelines could be retrieved, creating a selection of relevant drugs for medical students to study.
The list of essential diseases is aimed at the undergraduate medical training. In the Netherlands, newly graduated doctors work in a number of settings (hospitals, psychiatric institutions, youth health services, mental health services, occupational health and safety services, etc.), but their duties are similar – the day‐to‐day care of patients. The list of essential diseases clarifies what can be expected of recently graduated doctors without extensive clinical experience. As recently graduated doctors gain clinical experience, their (field specific) treatment repertoire should increase and become more detailed. As such, the essential diseases might help to clarify where undergraduate medical education ends and where post‐graduate (field specific) training should begin.
Unlike previous studies 8, 9, we used an established consensus method involving a group of 62 educational, pharmacological, and clinical experts, to make a comprehensive list of diseases for which junior doctors should be competent prescribers. Moreover, the consensus panel included junior doctors, who are arguably the best experts on what is needed in daily clinical practice. The total number of essential diseases identified (n = 63), is comparable to the number of diseases recognized as “must know how to manage” (n = 67) by Orme et al. 9. In contrast, Ross and Maxwell identified 124 diseases 8. However, they included conditions that junior doctors ‘should not necessarily be able to prescribe for <...> from day 1’. Their list included complex diseases such as breast cancer, dementia and Parkinson's disease, which were not selected in our Delphi study. We would like to stress that we do not advocate not teaching medical students how to treat these diseases, rather we recognize that junior doctors cannot be expected to be fully competent to manage these diseases on their own.
Our study had several limitations. Only two paediatric conditions were included in the list (i.e. acute otitis media in children; febrile convulsion), possibly because there were no paediatricians on the consensus panel. However, we did include general practitioners, junior doctors working in paediatrics and teachers in pharmacotherapy, who can be presumed to have reasonable insight into what can be expected of junior doctors regarding paediatric medicine. Nevertheless, the authors do sense (historical) inattention for the training to prescribe for children.
The low number of diseases (n = 5) in the category Surgery, Urology and Gynaecology is possibly because these conditions tend to be treated surgically rather than medically. Another explanation is there were more specialists in internal medicine than surgeons on the consensus panel, potentially causing selection bias. The precise classification of diseases to certain medical disciplines should not be emphasized too much, however, as many therapeutic problems are relevant to multiple disciplines alike (e.g. hypovolaemia, constipation and pain).
Interestingly, some serious and prevalent conditions did not get selected as essential diseases, such as heart failure, shock and sepsis. An inherent drawback of our Delphi design is that we do not known why panel participants included or excluded certain diseases. It is possible that the panel participants did not expect junior doctors to be able to treat these conditions independently, which was a strict inclusion criterion. Another explanation might be the strict 80% cut‐off, which is often used, yet remains arbitrary. The above‐mentioned conditions made it all to the second round, indicating that more than 50% of the respondents did think junior doctors should be able to treat these diseases on their own. We only selected essential diseases; clearly, there are more diseases junior doctors should be aware (yet not necessarily treat independently). See also Appendix S3.
An interesting finding is that all the medical conditions, except hypovolaemia, are included in the guidelines for general practitioners in the Netherlands 26. Indeed, both junior doctors and GPs may be seen as generalists and should be able to prescribe competently for the selected diseases. Of course, the expertise of GPs is more wide ranging, as is [evident from] the total number of therapeutic problems that is included in their guidelines 26.
This study of essential diseases was a national initiative, as only Dutch experts participated. Nonetheless, the selection may be informative to medical schools in countries with similar length of medical training and hierarchical position of junior doctors, or countries were medical accreditation is recognised across borders (e.g. in the EU). In 2002, Orme et al. 9 noted that a disease‐oriented curriculum designed in one country could be adapted to another country with little difficulty (from the UK to Germany, in their case) 17. Recently, an international study of European learning outcomes in pharmacotherapy argued the need to update the list of specific diseases that junior doctors should know how to treat 20. We believe that the list of essential diseases may provide a good starting point for such update.
Conclusion
This study provides a list of essential diseases for which a junior doctor must be competent to prescribe. Consensus for these essential diseases is obtained in an extensive and diverse group of (clinical) professionals. The selected diseases provide relevant topics for pharmacotherapy education and offer rational items for formative and summative evaluation of prescribing competence.
Competing Interests
There are no competing interests to declare.
We would like to thank all participants for their suggestions, enthusiasm and invested time.
Supporting information
Appendix S1 Initial questionnaire (n = 220)
Appendix S2 Detailed explanation on the indicated level of prescribing competence (as was given to the participants)
Appendix S3 Delphi scores for all accepted items and all items reassessed in Round 2 (bar indicating 80% cut‐off for acceptation)
Jansen, B. H. E. , Disselhorst, G. W. , Schutte, T. , Jansen, B. , Rissmann, R. , Richir, M. C. , Keijsers, C. J. P. W. , Vanmolkot, F. H. M. , van den Brink, A. M. , Kramers, C. , Vondeling, A. M. , Dumont, G. J. H. , de Waard‐Siebinga, I. , Van Agtmael, M. A. , and Tichelaar, J. (2018) Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education. Br J Clin Pharmacol, 84: 2645–2650. 10.1111/bcp.13730.
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Associated Data
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Supplementary Materials
Appendix S1 Initial questionnaire (n = 220)
Appendix S2 Detailed explanation on the indicated level of prescribing competence (as was given to the participants)
Appendix S3 Delphi scores for all accepted items and all items reassessed in Round 2 (bar indicating 80% cut‐off for acceptation)