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|BMJ 2006;333:601 (16 September),
A prescription for better prescribing
Summary of responses
Many of the 18 other responses to the editorial by Aronson et al (mainly from UK based doctors and pharmacists) emphasised the importance of teamwork and communication as key to improving prescribing.1 The dean of the University of East Anglia Medical School, Sam Leinster, and his pharmacology lecturer colleague Yoon Loke were, however, concerned that the editorial had drawn conclusions about the quality of teaching before the data had been collected and evaluated.
Proposed solutions to the perceived problem include drawing on the skills of (clinical) pharmacists or nurse practitioners; separating the disciplines of diagnosis and prescription and using two different professionals ("diagnosticians" and "therapeuts"); using prescribing advisers in primary care trusts or specially trained clinical pharmacologists; gaining additional postgraduate certifications; making decision aids available through information technology, on personal digital assistants, or in the shape of the (electronic) BNF or Drugs and Therapeutics Bulletin... The list goes on: additional training shifts on the wards for senior medical students and increased or prolonged supervision of student doctors by different types of professionals.
By way of improving training, a programme of teaching and reflective learning has been developed at the University of Dundee Medical School, the Appropriate Prescribing for Tomorrow's Doctors project. Developed by specialists in infection and medical education, it has now been adopted by medical schools throughout the UK. The programme's primary resource is an interactive website with access to clinical worked examples, prescribing exercises, self assessment tools, and a reflective learning logbook.
London based primary care professor Azeem Majeed and colleagues discuss the topic of admissions to hospital as a result of adverse drug reactions—a possible consequence of poor prescribing—and conclude that we do not have good enough data to draw conclusions on how to improve prescribing, something that Nicholas Moore, professor of clinical pharmacology in France, echoes but thinks that any admission for an adverse reaction is reason to try to improve the practice of prescribing.
D B Double, consultant psychiatrist in Norfolk, looks at the issue from another angle, arguing that overprescribing may be as much a problem as underprescribing. Doctors need to focus on the patient to get it right, as not every patient may be after a prescription in the first place.
Bevan J Clayton-Smith, research fellow at the Research Centre for Mãori Health and Development, concludes with a concept that others in essence support, that behind every good prescriber is a good relationship between pharmacist and physician. It seems a good starting point.
Birte Twisselmann, assistant editor (web)
Competing interests: None declared.
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