What do Medical Students need to know about Drugs?

And how should we assess them?

Michael OrmeUniversity of Liverpool , U.K. andEuropean Association for Clinical Pharmacology and Therapeutics

European Association for Clinical Pharmacology and Therapeutics

(EACPT)

• EACPT was founded in 1993 and runs biennial congresses.

• 32 European Countries are in membership

• EACPT Education Sub-Committee started work in 1997

European Medical Schools

• Some 400 medical schools in “Europe”

• Great variety of administrations and courses.

• For example Russia

Russian Medical Schools

• Stretch from St. Petersberg to Vladivostok• On average each school teaches 200

hours of ‘pharmacology’ ( 50 lectures, 65 demonstrations, 85 hrs of self study)

• Assessment is by factual recall• Elsewhere in Europe ‘hours’ are difficult to

calculate and many different curricula exist such as problem-solving or problem based.

Importance of Clinical Pharmacology teaching for Clinical

Care

• Case already made by previous speakers

speakers!

* Thus how should we teach?

What Should Medical StudentsKnow About Drugs

• The idea of a Core Curriculum

• The importance of Basic Science

• At Least three approaches

• Core Knowledge and Understanding

• An essential drug list ( not WHO )

• A Disease Based approach

Core Knowledge and Understanding

• Eg Basic Pharmacology,• Clinical Pharmacokinetics• Adverse Drug Reactions/ Pharmacovigilance

• Medication Errors, Drug Interactions, • Prescribing for the Elderly /Children• Prescribing in Patients with Liver or Kidney

disease• New Drug Development

Core Knowledge and Understanding

Core Skills

• Taking a drug history

• Drug Allergy

• Drug Administration

• Analysis of New data

• Prescription Writing

Core Knowledge and UnderstandingCore Attitudes

• A Rational Approach to Drug Prescribing• Life Long Learning• Risk Benefit Analysis• Cost Benefit Analysis• Responsibilities of a Prescriber• Recognition of the role of other health care

workers in the field –eg Pharmacists

Core Curriculum Essential Drug List

• Not necessarily based on WHO system

• Preparation of a list of perhaps 120 drugs

to be known in some detail by students

• In some case students prepare their own formulary ( eg P drugs )

• There will be perhaps 80 or so other drugs the student should be aware of

Core Curriculum –Drugs (1)What should the student know about the Core

Drugs?

• Drug Name – generic or approved

• Drug Class - ?alternatives• Indication – Route and Dose ?Look Up

• Adverse Effects

• Elimination –and effects of disease

• Drug Interactions

• Patient Information

Core Curriculum – Drugs (2)

• Core Drugs in Hypertension * Calcium Channel Blockers ( eg Amlodipine ) * ACE Inhibitors ( eg lisinopril ) * Diuretcis ( eg Bendrofluazide ) * Selective Beta Blockers ( eg Atenolol) * + AT1 receptor antagonists ( eg Losartan ) * + Centrally Acting Drugs ( eg Clonidine ) * + Alpha Blockers ( eg Prazosin ) + Indicates the need for student awareness

Core Curriculum – Drugs ( 3 )

• Respiratory Drugs *Inhaled Glucocorticoids ( eg Beclomethasone)

* Beta 2 Agonists ( eg salbutamol, Salmeterol) * Ipratropium * Theophylline * [Codeine ] * + Cromoglycate * + Leukotriene Antagonists ( eg Montelukast) * + Acetylcysteine [ ] indicates the drug is found elsewhere in formulary

Core Curriculum – Diseases

• Code M - Diseases that students must know how to manage ( n= 67 )

• Code D - Diseases that students must know how to diagnose ( n = 158 )

• Code A - Diseases that students should be aware of ( for specialist care ) (n=36 )

Core Curriculum –Diseases (2)

• Typical Code M Diseases * Acute Myocardial Infarction

* Deep Vein Thrombosis

* Diabetes Mellitus

* Constipation

* Urinary Tract Infection

* Angina

* Gout

Core Curriculum – Diseases (3)

• Typical Code D Diseases * Bacterial Endocarditis

* Jaundice

* Nephrotic Syndrome

* Parkinson’s Disease

* Bronchial Carcinoma

* Limb Fractures

* Ectopic Pregnancy

Core Curriculum – Diseases (4)

• Typical Code A Diseases * Addison’s Disease

* Cirrhosis of the Liver

* Bladder cancer

* Schistosomiasis

* HIV/AIDS

* Cystic Fibrosis

* Motor Neurone Disease

Core Curriculum - Diseases

• The Disease system has worked well in those European Countries where it has been piloted.

• However world wide the criteria for codes M,D and A may well need to change

How Should they be assessed?

• Should examinations be Nationally, Regionally or Medical School based?

In Europe most are school based• Should there be a specific examination in

clinical pharmacology or rational prescribing?

With the advent of integrated curricula specific CPT exams have largely gone. Good thing or Bad Thing?

Core Curriculum in CPT Assessments

• Assessments drive the curriculum

• Students will usually learn only those areas that they think will be exam tested

• A variety of assessment methods may be needed depending on circumstances

Assessements (1)

• Knowledge based Multiple ( True/False) choice exams ( MCQs) are often unreliable and

measure only factual knowledge. • Problem solving MCQs give a better assessment * OSCE’s ( Objective Structured Clinical Exams)

can be useful but station size is usually limited

Assessments (2)

• Essay writing is usually a waste of time for students and examiners

• May be better if model answers are agreed

• Short essays ( eg 10 lines) are possibly the best written test if model answer is used and scripts are double marked

Assessments (3)

• Ideally there should be an assessment of the ability to prescribe safely and rationally

• This can be achieved in an OSCE (OSPE)

but it is difficult to have more than a few stations.

* Should some stations carry an automatic failure? ie if you fail the station you fail the exam.

Conclusions

• Much work remains to be done to assess the European situation and to try to produce effective education so that doctors are able to prescribe rationally and safely