Solomon et al discuss how strictly enforced prescribing guidelines can limit patient choice and may be detrimental to the doctor–patient relationship and shared decision making.1 However, in their study many GPs employed a pragmatic approach, being flexible and applying guidelines in the context of individual patients. I feel that this is a skill that needs to start being developed early on in medical training.
The General Medical Council mandates that medical graduates must be able to ‘prescribe drugs safely, effectively, and economically’.2 Prescribing is one of the biggest leaps in the transition of a medical student to a doctor. However, a study done last year found that a large proportion of graduates entering the foundation programme felt under-prepared for prescribing.3 Moreover, participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. A recent review demonstrated that current undergraduate prescribing education neglects important factors such as the social context of the workplace and the patient, hindering a real-life integrated approach to prescribing.4
Some medical schools have introduced a prescribing exam, and the British Pharmacological Society and Medical Schools Council are currently working together to introduce a national prescribing skills assessment for all graduating medical students in the UK. Having just undertaken my final exams I feel that existing assessments, including the prescribing exam and objective structured clinical examinations, mainly assess safe prescribing. I believe there is a place in the medical school curriculum for training to help students appreciate the ‘real-world’ applicability of clinical guidelines, including patient refusal, patient demand, and conflicting priorities. For example simulated training with actors and then with real patients on general practice attachments, acquiring feedback in the process, may be particularly beneficial. GPs who tutor students can also provide feedback on their progression in this domain across the attachment.
The art of negotiation and adopting a patient-centred approach to prescribing while practising safe evidence-based medicine is one that takes many years to acquire. Early training may be invaluable particularly for those with future aspirations in primary care.
- © British Journal of General Practice 2012
