The prescription conundrum

This week as part of my studies at Edinburgh we touched on the issue of drug prescribing. Prescribing is considered by many to be the role that epitomizes the medical profession. It’s a tool which is in some way unique to doctors (at least in terms of the extent to which they utilize it) and is the major way by which we apply our knowledge and skills to care for patients. Prescribing medication is far more than just writing words on a piece of paper – it is a dynamic and multi-layered process by which the physician identifies and details the approach to management, conveys this message to the patient, gains feedback and ‘tweaks’ the treatment for optimum results.

One thing about prescribing is that, despite its complexity, the lower you go on the medical ‘hierarchy’ so to speak, the more prescriptions you find. Junior doctors do the most prescribing – simply because they are often the ones who have the most contact with patients. Despite this, many junior doctors do not feel they are equipped with enough knowledge, skill or experience to effectively (or even safely) prescribe after graduating medical school. I certainly thought so.

Two semesters of pharmacology (the study of the actions of drugs) and one of therapeutics (the application of pharmacology in the use of medicines to treat disease) left me with a decent knowledge of the way drugs interact with the body (and vice versa), and of which medicine to use in which situation. But about prescription writing? Nothing. I scribbled my first prescription as a junior house officer in my pediatrics rotation – I can’t remember exactly what it said but I can imagine it contained about as much meaningful medical information as my left big toe. Thankfully the medication was to be dispensed from the internal pharmacy at the hospital where I worked, and the pharmacist was nice enough to make a few comments about my prescription writing technique.

Now, the thing is that this seems to be a universal problem among junior doctors – there simply isn’t any opportunity to practice prescription writing in a real-life setting during medical school. The result is that a lot of mistakes are made – meaning unnecessary drugs are prescribed, avoidable side effects are observed, costs of treatment increase and medico-legal issues arise. But it’s not fair to pin the blame solely on junior doctors – both from my experience and from several formal studies conducted, senior doctors also make a fair amount of prescribing mistakes, and many do not implement an optimum prescribing technique. Moreover junior doctors tend to have a more solid knowledge of the more basic aspects of drug action and interaction than their senior counterparts – the ‘is vancomycin an aminoglycoside?’ debate I once had with one of my senior colleagues lingers in my memory (Sometimes I wonder if I should avoided the topic altogether and better utilized that hour of my life, but the distinction isn’t exactly arbitrary, aminoglycosides’ use is mainly limited to gram-negative bacteria while vancomycin has a much broader spectrum, but I digress …).

So a year later after completing my internship I’m slightly better at prescribing – I’ve learned to dot the i’s and cross the t’s, but the need to reform this aspect of medical education is undeniable.

More on prescribing soon!

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