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Undergraduate training in
rational therapeutics - does it have any impact at all on
actual prescribing?
The world over a lot of soul-searching is going on as
to whether training of undergraduates on good prescribing
practice and rational therapeutics has any impact on
future prescribing habits. A recent issue of the
newsletter of the International Network on Rational Use
of Drugs (INRUD News Vol. 8, No. 1, February, 1998)
presents viewpoints from authors in various countries ¾
both developed and developing. The fact that prescribing
habits of doctors in practice leaves much to be desired,
is universally acknowledged. Student doctors and nurses
do receive training on therapeutic principles and
rational use of drugs and are willing to learn. But once
qualified and in the workplace, they are under pressure
to prescribe, which leads them to quickly jettison
principles and therapeutic rationales, identify a safe
prescribing peer, and copy the peer’s habits. A
number of potentially modifiable factors contribute to
the mess:
- Undergraduate
training in pharmacology, in most medical
schools, is still focused on pharmacological
properties of drugs in a rather theoretical
fashion with much less emphasis on clinical
pharmacology.
- Training on rational
therapeutics, when given, tends to be too short,
one-time only and not appropriately timed.
Training only in the preclinical years without
further reinforcement or training during the
residency period when core prescribing habits
have already developed, are both inadequate.
- Lack of standard
treatment guidelines, lack of implementation of
such guidelines where they do exist and lack of
audit of drug use in clinical situations.
- Poor communication
between doctor and patient. All too often drugs
are used as short-cuts, in lieu of counseling,
and the importance of lifestyle modifications and
non-drug therapeutic modalities are not stressed
or explained to the patient.
- Emphatic, and at
times unethical, promotion by the drug industry.
- Apathetic attitude of
the prescribing fraternity in view of the lack of
incentives for good prescribing and, conversely,
lack of disincentives for irrational prescribing.
Changing established
prescribing habits is a Herculean, if not impossible,
task. A better way would be to begin more relevant
therapeutic education during the preclinical years and
continue this throughout the clinical training period of
undergraduates. Evidence based medicine is gaining
currency and this needs to be stressed in all clinical
situations. This has to be coupled with a continuous
therapeutic revision process, in which practicing
physicians are encouraged to take active and leading
roles. Ultimately, it is the spirit of self-monitoring
which can have the greatest positive impact on rational
drug selection and prescription.
Avijit Hazra
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