World Health Organization Essential Drugs and Medicines Policy Geneva

WHO/EDM/PAR/2001.2 DISTRIBUTION: GENERAL ORIGINAL: ENGLISH

Teacher’s Guide to Good Prescribing

World Health Organization Department of Essential Drugs and Medicines Policy Geneva, Switzerland

Authors Hans V. Hogerzeil1 (Editor) Karen I. Barnes2 Rob H. Henning3 Yunus E. Kocabasoglu3 Helene Möller4 Anthony J. Smith5 Rob S. Summers6 Theo P.G.M. de Vries7 with contributions from Hannelie Meyer, Sule Oktay, Budiono Santoso and Sri Suryawati
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WHO Department of Essential Drugs and Medicines Policy, Geneva, Switzerland WHO Collaborating Centre for Drug Policy, Information and Safety Monitoring, Department of Clinical Pharmacology, Medical School, University of Cape Town, Cape Town, South Africa WHO Collaborating Centre for Pharmacotherapy Teaching and Training, Department of Pharmacology and Clinical Pharmacology, Medical Faculty, Groningen University, Groningen, The Netherlands WHO, South African Drug Action Programme, Pretoria, South Africa WHO Collaborating Centre for Pharmacotherapy Teaching and Training, Discipline of Clinical Pharmacology, Medical School, Newcastle, Australia WHO Collaborating Centre for Pharmacy Curriculum Development and Rational Use of Drugs, School of Pharmacy, Medical University of Southern Africa, Pretoria, South Africa Department of Pharmacology, Medical Faculty, University of Amsterdam, Amsterdam, The Netherlands

Acknowledgements
The support of the following persons in reviewing earlier drafts of this book is gratefully acknowledged: F. Danish (Kabul, Afghanistan), A. Haeri (Tehran, Islamic Republic of Iran), A. Helali (Algiers, Algeria), K.K. Kafle (Kathmandu, Nepal), R.O. Laing (Boston, USA), J.C. Lombard (Sovenga, South Africa) and I. Moodley (Johannesburg, South Africa).

© World Health Organization 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Printed in France

Annex 4

Contents

Introduction Part 1: How to teach pharmacotherapy with the Guide to Good Prescribing Chapter 1: The role of the teacher Chapter 2: How to write learning objectives Chapter 3: How to construct good patient examples Chapter 4: Teaching notes for the Guide to Good Prescribing Chapter 5: Developing critical appraisal skills Chapter 6: Application in primary care settings Part 2: How to assess the students, the teachers and the course Chapter 7: How to assess the students Chapter 8: How to assess the teachers Chapter 9: How to measure the impact of the training Part 3: How to mobilize support Chapter 10: How to mobilize support for problem-based pharmacotherapy teaching Annexes 1: Examples of patient cases used for training paramedical workers in South Africa

1 5 7 11 15 21 35 45 49 51 67 69 75 77

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2: Example of a prescribing score sheet used for paramedical workers in South Africa 91 3: Examples of patient cases used in a research study in Yemen 4: Example of a scoring form used in a research study in Yemen Authors by chapter 92 96 98

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Introduction

Introduction

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rrational prescribing is a “disease” which is difficult to treat. Prevention is possible however. For this reason the WHO Department of Essential Drugs and Medicines Policy aims to improve the teaching of pharmacotherapy to medical students.

The Teacher’s Guide to Good Prescribing is a companion volume to the Guide to Good Prescribing. Its target audience is university teachers who wish to use the Guide for teaching undergraduate medical students. Its main objectives are: to explain the educational approach underlying the Guide; to explain how to teach pharmacotherapy with the Guide; to give practical advice on how to assess the students, the teachers and the course; and to assist in mobilizing support for problem-based pharmacotherapy teaching.

The WHO Guide to Good Prescribing
Surveys in Canada, the USA and Europe have concluded that structured training in pharmacotherapy is relatively uncommon. In many medical schools pharmacotherapy teaching is characterized by the transfer of knowledge about drugs, rather than by the skill to treat patients. However, in the last decade a number of educational programmes have been developed to improve the teaching of pharmacotherapy. Based on positive experiences in Groningen (The Netherlands), followed by a large international study involving seven medical schools in developed and developing countries,1 WHO has developed a manual for undergraduate medical students on the principles of rational prescribing, the Guide to Good Prescribing.2 This manual presents the students with the following normative model for pharmacotherapeutic reasoning. First, students are taught to develop a standard treatment for common disorders, resulting in a set of first-choice drugs, called P(ersonal)-drugs. In the course of developing their P-drugs, students are taught to consult existing national and international treatment guidelines, formularies, textbooks and other sources of drug information. Then they are shown how to apply this set of P-drugs to specific patient problems, using a six-step problem-solving routine: (1) define the patient’s problem; (2) specify the therapeutic objective; (3) verify the suitability of your P-drug and choose a treatment for this individual patient; (4) write a prescription; (5) inform and instruct the patient; and (6) monitor and/or stop the treatment. The rationale behind this approach is that medical students develop, at some time in the course of their studies or early in their career, a set of drugs which they will use regularly from then on. However, this choice of drugs is often made on irrational grounds, e.g. by copying the prescribing behaviour of clinical teachers or peers without considering
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De Vries TPGM, Henning RH, Hogerzeil HV, Bapna JS, Bero L, Kafle KK, Mabadeje AFB, Santoso B, Smith AJ. Impact of a short course in pharmacotherapy for undergraduate medical students. Lancet 1995;46:1454–7. De Vries TPGM, Henning RH, Hogerzeil HV, Fresle DF. Guide to good prescribing. Geneva: World Health Organization; 1994. WHO/DAP/ 94.11.

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Teacher’s Guide to Good Prescribing

alternatives or knowing how to choose between them. The Guide to Good Prescribing not only helps students to select P-drugs in a rational way, but also to consult, understand and use existing treatment guidelines. For example, it teaches the students how to verify, for each individual patient, whether their P-treatment is also the most appropriate choice in this individual case; and, if necessary, how to adapt the drug, the dosage form, the dosage schedule, or the duration of treatment. Further on in their careers doctors are subject to many other influences on their prescribing, including scientific publications, commercial information and patient pressures. The Guide makes students aware of these influences and helps them to make optimal use of the information available to them to update their P-drugs in a rational way. The Guide to Good Prescribing has been widely acclaimed as an innovative and very practical teaching tool. Although published by WHO it can be freely abstracted, translated and reproduced, in part or in whole, but not for sale or for commercial purposes. It can also be downloaded from the following website: http://www.med.rug.nl/pharma/who-cc/ggp/ homepage.htm/. In practice, this means that there is no need for students to procure original copies, as the Guide can easily be reproduced as part of student hand-outs. By 2000 it had been translated into 18 languages.

Problem-based pharmacotherapy teaching
The six-step routine offers a logical structure to guide students through the process of pharmacotherapy, and using the Guide for self-study is probably beneficial in itself. However, medical students need to be trained in additional skills necessary to apply the method successfully in pharmacotherapy. The training of cognitive skills requires special teaching methods, and the recommended teaching method is problem-based learning in small groups. s Problem-based In addition, specific educational methods are required to teach pharmacotherapy communication skills, such as using simulated patients and teaching is possible bedside teaching. The main message of this Teacher’s Guide is that problem-based pharmacotherapy teaching is possible within a traditional within the structure of a traditional (non problem-based) curriculum curriculum. This manual contains practical information on how to implement it.

The link with clinical training
Problem-based pharmacotherapy teaching alone, either as an introductory course before students enter the wards or as an ongoing part of integrated clinical teaching, is not enough to “vaccinate” medical students against the pressures towards irrational prescribing that they will face in their professional career. A first risk period, and probably the one with the strongest influence, is the time of clinical attachments and junior clerkships. After some years of mainly theoretical studies most students are eager to become clinically active and are very sensitive to the role model of their clinical teachers. Unfortunately, irrational prescribing is widely reported from teaching hospitals,3 while clinical teaching of undergraduate students is often insufficiently planned and supervised,

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Hogerzeil HV. Promoting rational prescribing—an international perspective. British Journal of Clinical Pharmacology 1995;39:1–6.

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Introduction

and usually delegated to junior staff. Any irrational prescribing behaviour in the wards will therefore almost automatically be copied by the juniors. Even on those occasions when the students have the chance to observe the example of clinical professors and consultants, their prescriptions may reflect the treatment of a rare disease or difficult complications and do not necessarily represent the type of patient problems the students are likely to meet in the first years of their professional life. Therefore, pharmacotherapy teaching should not only be problem-based but should also be based on clear objectives (Chapter 2). What type of doctor should the undergraduate curriculum produce? Which types of diseases and complaints should the young graduates be able to recognize and treat? Which drugs should they be able to use effectively and confidently? And which skills are needed to choose the right treatment and adequately inform the patient, and to read information on new drugs with a critical eye and get the maximum benefit from it? It is essential that these skills, once taught in the undergraduate phase, be reinforced during the clinical attachments. The set-up and academic content of these attachments should reflect this. Chapter 5 summarizes some innovative teaching ideas from medical schools in developed and developing countries. Since 1994, when the Guide to Good Prescribing was published, the book has also been used as the basis for teaching paramedical prescribers, such as medical assistants and nurses, within in-service training programmes. This application of the Guide was therefore innovative in two aspects: paramedical students, and in-service training. This aspect is discussed in Chapter 6. While the teaching method aims to transfer the practical skill of prescribing rather than just the knowledge on drugs, the method of assessing the students must also reflect this objective. Here continuous assessment methods should be considered, as well as openbook examinations and objective structured clinical examinations. Part 2 contains practical information on how to organize such examinations and ends with a chapter on how to mobilize support for problem-based pharmacotherapy teaching (Chapter 10). This Teacher’s Guide has been developed by a group of authors working under the responsibility of the WHO Department of Essential Drugs and Medicines Policy. Comments on the text and the examples in this manual, as well as reports on its use are actively solicited and should be sent to the Director of the WHO Department of Essential Drugs and Medicines Policy, 1211 Geneva 27, Switzerland (fax + 41-22-7914167).

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PART 1

How to teach pharmacotherapy with the Guide to Good Prescribing

Chapter 1. The role of the teacher

CHAPTER 1

The role of the teacher
Be glad they make mistakes, there is no better opportunity to teach them.
Modified from M. Gaus, dog trainer

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f you are reading this book you are probably interested in improving the teaching of pharmacotherapy. You may have read the WHO Guide to Good Prescribing, and you may be thinking about implementing parts of it.

Two concepts lie at the heart of the Guide to Good Prescribing and this accompanying Teacher’s Guide to Good Prescribing: the six-step logical method to teach prescribing, and the problem-solving learning method. The six-step logical method was first developed and used in Groningen (The Netherlands) and has proved very useful in many other settings, including the teaching of paramedical workers. Teachers have usually adopted the essentials of the method very quickly, as most of them are already familiar with clinical work and pharmacology. However, the main risk for teachers is to keep focusing on the transfer of knowledge rather than on the skills of selecting and prescribing the right treatment. The students should be taught how to prescribe, not what. As one teacher said: “The drug they select is their responsibility, but the way they do it is mine”. The second concept underlying the Guide to Good Prescribing is problem-based learning, a concept with which most teachers are much less acquainted. This situation is probably related to the fact that few medical schools around the world use problem-based curricula. It is therefore assumed that you are not experienced in problem-based teaching. You may, however, have various ideas about the concept, ranging from unrestricted support to vigorous disagreement. Research over the years has shown that students who have been trained by problem-based learning methods gain about the same level of knowledge, but perform better on skills and attitude compared to students from traditional curricula. Moreover, students enjoy problem-based learning much more, and so do many teachers. It is a common misunderstanding to think that problem-based learning can only be used in the setting of a full-blown problem-based curriculum, where students work in small groups supported by costly logistic and technical facilities. However, problem-based learning is what it says: driven by the quest for the solution to clinical problems (by the students), and not by learning various subjects by heart from chapters of textbooks or hand-outs prepared by the teachers. Initially teachers may prefer working with smaller groups, as small group processes are easier to control; but it can also be applied to large audiences. Although the students are the main players in the learning process, problem-based learning is controlled by the teacher. The boundaries of learning are set by the teachers, and are based on the objectives of the teaching programme. Such objectives define which knowledge

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the students should acquire, which clinical problems they should be able to solve and which skills they should master, before they can qualify as a doctor. Fortunately, all students are already experienced problem-solvers although the process is largely subconscious. Consider the following example. Suppose that last night the roof of your house was damaged by a storm. Soon the rains will come. By then the roof must be fixed. Stop here, and think... By now, you have already thought of a number of solutions, although you do not have a degree in architecture or engineering. What is your knowledge about roofs anyway? Yet you will be confident that you can solve the problem, just as most people will. Why? Because you trust your problem-solving skills. The actual solution may vary from person to person. One may repair the roof by her/himself, the second may have a friend or a relative who can help, a third just hires somebody to repair the roof, the fourth moves to another house. All are correct! The way to get to the solution is universal: define the problem, make an inventory of potential solutions, choose the best option, and implement it. The nature of the problem is irrelevant. It can be a car which does not start, a patient with a cold, a patient with lymphoma. The role of the teacher is to trigger the problem-solving routine in the students, and to employ this natural human behaviour to guide them in solving patient problems. This process may sound easy, but for many teachers it requires a major shift in the way they deal with students. It requires a completely different approach, communication and attitude. The centre of the learning universe is no longer the “knowledgeable” teacher, but the students. Students and teachers become equal partners in the process, although they have different roles. The teacher stops lecturing and starts asking questions. Practice in conducting problem-based learning is the main thing you will need. Inform your students that you are not all that experienced, and that you would welcome suggestions on improvement. Plan your classes well and share those plans with the students. Start your fourth or fifth session by briefly reviewing the earlier ones. The moment you get any spontaneous response, you know you are on the right track. If you are inexperienced at problem-based learning, it is advisable to gather one or two colleagues or friends who are going through the same process. It may help to share your experiences, to swap classes, etc. Be fair with your students, and never be rude. Students often lack detailed knowledge of the disease you are discussing and of the properties of the relevant drugs. In the early stage this is a golden opportunity for them to learn how to use literature sources. Care should be taken not to ‘punish’ the students for lacking knowledge. At first some students may find your advice to look for the literature offensive or very threatening. Keep in mind that people learn from failures, especially if they discover the failures for themselves. A more-or-less correct answer from a fellow student is often much more convincing and motivating than your expert opinion. Therefore, allow the students to divide the work between a number of them (a solution which may horrify some teachers in traditional curricula) and arrange for a session in which they report back to the group. Encourage those students who propose wild or stupid ideas. Share with the group your observation on the roles that different students have. Often, comparing their roles with animals, sports heroes or politicians arouses much hilarity and gets you closer to the group. Never exclude yourself from any assessment within the group, and be prepared to be compared

s The teacher stops lecturing and starts asking questions

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Chapter 1. The role of the teacher

to an animal yourself! If students are hesitant to express themselves, ask them to write things down, anonymously if necessary. The final challenge for a problem-based learning programme, and for the teachers, is to give the group or the individual students the opportunity to treat real patients under supervision, for example as part of clerkships. Practice makes perfect! Chapter 8 presents some suggestions on how to assess your role as a teacher, including an example of a student observation sheet.

BOX 1. PRACTICAL HINTS FOR PROBLEM-BASED TEACHING s Get the students to sit in a circle or around a large table. Sit among them or in a corner of the classroom, but not in front of them. Define one objective for the teaching session, and inform the students about it. If you find it difficult to formulate clearly, prepare it in advance and write it on the blackboard. If necessary, attach a time frame. For example, the learning objective “to understand the steps you have to take to solve a patient problem” is quite different from “to choose the correct drug-treatment for a patient with asthma”. Start the session by defining one single problem, or extracting one problem from a complicated case. Make sure everyone understands that this is the problem. If the problem is likely to be too complicated, simplify it. Don’t interfere with the group during the first ten minutes of the session. Use this time to define the roles the group members play. When you feel that an intervention is needed, do not intervene immediately but continue to observe the group for several minutes (look at your watch: most moderators are tempted to act too soon). Then reconsider what you had wanted to say to the group, and change it if needed. If the group is chaotic or does not get going: start all over again after redefining the roles of its members (chair, reporter). Make clear what is expected from a student who fulfils a certain role, rather than just using him or her as a writer on the blackboard. Avoid eye contact with the student who is talking or trying to get attention. Often students are looking for your reaction while their colleague is talking. Only use eye contact or body language to direct them to the speaker. Think of interventions only as influencing the group process. There is quite a difference between an intervention on the group process level (with questions such as “Why are you not capable of solving the problem?”, “Why are some of you so quiet?”), compared to one at the content level (such as giving information on a certain drug, or questions such as “What would be the correct drug?”, or “What would be the next step?”). When intervening, address the group in general rather than a single individual. Groups work at a pace of their own. A slow pace need not be due to a lack of knowledge, but is often due to the group process. Address the problem of slow pace directly, with emphasis on the process and not on the content. It does not help to speed up a group by contentdirected interventions. Ask quiet students in the group to summarize, in order to find out whether they just did not prepare for the session or whether their silence is caused by the group process. Ask them what difficulties may be preventing them from participating; their reasons may also apply to other ‘quiet’ students. Each and every time you are planning to intervene on the content of the discussion (rather than the process), think of all of the above points. Count to ten, and then don’t intervene!

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CHAPTER 2

How to write learning objectives
Why do we need learning objectives?

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or most of us who began medical training many years ago, the idea of writing out specific objectives for courses or for individual teaching sessions may seem, at first, an unnecessary and rather bureaucratic exercise. However, if we think back to our own undergraduate days we will often remember the ill-prepared, rambling discourses that passed for lectures—frequently given by the most illustrious members of staff—and the examinations which seemed to bear little relation to anything we had been taught or learned on our own. Education was handed down from on high, and any suggestion that students or staff might evaluate the curriculum and its delivery would have been dismissed as unnecessary. Over the past two decades the influence of educationalists has made a slow but certain impact on medical and other health science teaching, and we now recognize the need for more structure in our programmes, and better advance planning. Formulating learning objectives is part of this planning process. A teaching objective, be it for a single lecture or for a whole course, is a statement of where you want the student to be after your teaching. In other words: what will the student be able to do after the teaching that s/he could not do before?

Examples of learning objectives For a course: At the end of this course, students will be able to apply the principles of the Guide to Good Prescribing to solve prescribing problems in cardiovascular diseases. For a single teaching session: At the end of this session, students will have learned how to select between different drugs on the basis of comparative efficacy, safety, cost and suitability, and will have practised this technique on a new problem not previously studied.

Learning objectives are a clear statement of what is expected of the teaching programme, but are also fundamental to the design of student assessments (“examinations”). Any examination is a sampling process. Not everything that has been taught and learned can be examined. If the teaching programme has clear objectives it is much easier to select items that are representative and to know to what depth to examine them. Many educationalists would say that creating your examinations should precede (not follow) the development of the teaching programme. Once you have decided what is important enough to be examined, you are better placed to decide how to teach it. In constructing an examination it is important to keep referring to the learning objectives of the course, in order to ensure that the examination is relevant, representative and fair.
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This approach also works to the advantage of students who will have a clear view of what is expected of them. Experience suggests that the inescapable stress of examinations is reduced if students have had clear objectives and know that the examination will be based on these objectives. Fear is often based on uncertainty! Objectives are also important for evaluating a session or a course. If we know where we want to be after the course, we can judge whether we got there—or in what way we fell short of realising the objectives. Students are always vocal critics, and a session with them evaluating a course at its conclusion may be very revealing. If the review session is focused on discussing the course objectives it will be much more critical and will avoid many of the trivial issues that could easily distract from the review of key concepts.

Example: Evaluating the teaching programme in Newcastle, Australia In Newcastle the undergraduate medical course is based on 47 programme objectives—basically statements of where and what the students are expected to be at the point of graduation. The assessment system is based on these objectives. Each year the examination effectively asks to what extent the students have achieved the objectives, appropriate to their level of seniority in the school. In the early 1990s, it was decided to embark on an “outcome evaluation” of the programme, to study how good the graduates were once they had left the medical school. However, this aspect proved very difficult to measure. It was eventually decided to measure the performance of the graduates against the original learning objectives. These objectives gave a firm statement of what was expected of the graduates. They were the best starting point for the evaluation of the programme.

How to write learning objectives
If objectives are to be central to progamme construction, examination and evaluation, they should be framed in such a way that they can be assessed. For example, “At the end of this session students should appreciate the principles of good prescribing for pain” may sound good as an objective—until you try to write an examination question. How do you test “appreciation”? A more concrete objective might read “At the end of this session, students will be able to write an appropriate and correct prescription for a patient with post-operative pain”. Now the goal of the teaching session, and the way in which it may be examined, are clear. In an evaluation it would be fairly easy to judge whether the teaching session had achieved its purpose. The six steps in the prescribing routine on which the Guide to Good Prescribing is based can easily be embodied in a teaching course as a set of objectives. Taken as a progressive series they might read: “At the end of this programme the student, when given a clinical scenario, will be able to: 1. Identify a patient’s problem 2. Specify the therapeutic objective 3. Select a drug on the basis of comparative efficacy, safety, cost and suitability 4. Write a correct prescription 5. Counsel the patient on appropriate use of the medicine 6. Make appropriate arrangements for follow-up.”
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Chapter 2. How to write learning objectives

Each of these is a concrete statement, and the way in which the programme might be examined is also clear. Points 1–3 refer to problem-solving and cognitive activity, and can be examined in that mode. Writing a correct prescription is a practical skill, which can be tested by asking students to write one or more prescriptions as part of their examination. Points 5–6 involve behavioural skills and are best tested as part of an observed interaction between the student and a real or simulated patient. An Objective Structured Clinical Examination (OSCE) is a useful structure for this part of the examination (see Chapter 7). Learning objectives for the individual sessions become more obvious as soon as the objectives for the course as a whole have been written. Such session objectives depend on the amount of time and the number of sessions available to you as a teacher, and the way you want to structure the programme. For example, if you have been allocated six sessions to introduce the principles of the Guide to Good Prescribing you would need to think very carefully about the emphasis you would put on each of the overall programme objectives in the time you have at your disposal. If you work in a problem-based medical school you might not need to put as much time into identifying and defining the patient’s problem, but perhaps more into specifying the therapeutic goal. If the six sessions are also to serve as a mini-revision of some therapeutic areas (e.g. if a course is set in the final year of a medical course) you may need more emphasis on the drug selection process, and the criteria for discriminating between different drugs and drug groups. If the course is set up with a major curricular emphasis on behavioural science and learning interpersonal skills, you might concentrate on the behavioural aspects of the prescribing process. However the course is structured, its objectives should specify what each session will include, and where you expect the students to be in knowledge, understanding and practical skills at the end of the session.

Conclusion
Writing teaching objectives takes time and thought, but once they are written and agreed upon they provide the essential foundation for constructing and maintaining a teaching programme, for assessing the students and for evaluating the course itself. Objectives “anchor” the course, and the time spent in putting them together is never wasted. Some more information on learning objectives for pharmacotherapy teaching is given in Chapter 5.

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Chapter 3. How to construct good patient examples

CHAPTER 3

How to construct good patient examples he best patient examples are to be found in outpatient clinics or hospital beds— that is, in the real world of the clinical encounter. Applying the principles of the Guide to Good Prescribing at the bedside, with a real prescription as an outcome, is clearly the best way to simulate the process that is undertaken by doctors at least 200,000 times in a lifetime of medical practice. However, reality dictates that students must learn the prescribing process by using patient problems that are constructed by the teaching staff. These problems should be specially designed to lead the discussion down particular channels (avoiding tempting side-issues which could take up time and would distract from the main aim). In the rest of this chapter it is assumed that: • a patient case will be worked through in a tutorial setting with an experienced tutor • the objectives of the session are clear • the tutor has a series of issues to be discussed and a clear concept of where the tutorial is to end • the six steps of the problem-solving routine of the Guide to Good Prescribing are part of the tutorial.

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Steps in constructing a clinical scenario
Step A. Make sure the focus is on therapy and not diagnosis
As you write the mini case history, make sure that either the diagnosis is stated, or sufficient clues are provided for it to be absolutely explicit. There is nothing doctors and medical students like more than a good discussion about a difficult diagnosis. Give your students not quite enough diagnostic information, and they will attack the scenario like piranhas and tear apart the diagnostic material, call for more information, claim the problem is insoluble in its present form, and totally ignore the therapeutic issues you wanted to focus on.

Example of a clinical scenario with bad diagnostic information “… A man of 45 has recurrent blood pressure readings around 160/95. He has no symptoms and wants to know whether treatment should be initiated …” At an international conference on clinical pharmacology, the process of the Guide to Good Prescribing was presented by means of a demonstration of a teaching session, with senior pharmacologists as “students”. One of the student groups spent 50 of its 60 allocated minutes discussing the adequacy of the diagnostic information of this patient with benign hypertension. The skilled facilitator of the group could not get to a discussion of treatment, even though the group had been asked to arrive at a prescribing decision. Instead, the discussion went into the accuracy of measurement, the number of readings required to be sure hypertension had been 15

Teacher’s Guide to Good Prescribing

established, the extent of investigations needed, and the nature of his family history! In the remaining ten minutes of the session they barely scratched the surface of many therapeutic issues—drugs versus non-drug treatment, choice between drug groups—which should have occupied most of the time. The case would have been much more useful had it been written as “A man of 45, with established benign hypertension and no evidence of underlying primary cause or of target organ damage, requires treatment. How would you proceed?” This scenario would have pre-empted the diagnostic discussion and would have led quite easily to the treatment issues and to the six points of the Guide to Good Prescribing.

Do not be afraid to state the diagnosis. Both cases below, though rather brief, have sufficient clinical detail to give reality to the presentation. Both, explicitly or implicitly, lead to a rapid diagnostic decision (malaria and pulmonary embolus) and the scene is set for spending the rest of the time on a discussion of therapy.

Two examples of clinical scenarios with good diagnostic information A woman of 36 has had intermittent fever for 6 days, with rigors, headache and anorexia. A thick film of her blood shows many red cells invaded with P. falciparum. A man of 62 has undergone hip surgery, complicated by deep venous thrombosis on the operated side. On the ninth post-operative day he experiences a very sudden severe pleuritic pain in the right chest. He has had a small haemoptysis and has a tachycardia of 120 beats per minute.

Step B. Modify your patient case to bring about special teaching points in drug choice
The difficulty of a clinical scenario for students can be increased or decreased by simple changes in the clinical story.

Example of a simple scenario A man of 52 has developed inflammatory arthritis in several small joints in both hands. Paracetamol has not helped. He is intolerant of oral aspirin. What symptomatic relief can you provide?

This scenario has blocks in place by making paracetamol ineffective and by making the patient intolerant of aspirin. The discussion would probably revolve around the choice (on the basis of efficacy, safety, cost and suitability) of a non-steroidal anti-inflammatory drug. This could yield a very productive session. Now alter the scenario in a very simple way by adding the text in italics:

Example of a small change which complicates the scenario A man of 52 has developed inflammatory arthritis in several small joints in both hands. Paracetamol has not helped, and he is intolerant of oral aspirin. He receives long-term warfarin following heart valve surgery two years ago. What symptomatic relief can you provide?

You could also add “He has had recurrent problems with peptic ulcer disease, and is taking ranitidine 150 mg twice daily”. With these additions you have altered a fairly simple problem
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Chapter 3. How to construct good patient examples

into a much more complex issue of either potential interaction with warfarin or the risk of aggravating peptic ulcer disease. Let us look at another example.

Example A 62-year old man presents with classical angina pectoris. You wish to prescribe a prophylactic for him as well as provide immediate treatment for the attacks.

Now add one word to the scenario and the discussion changes completely:

Example A 62-year old asthmatic man presents with classical angina pectoris. You wish to prescribe a prophylactic for him as well as provide immediate treatment for the attacks.

In the second scenario the selection of the most appropriate drug is totally changed by the patient’s asthma. By modifying other aspects of your case, other considerations come into force. The same patient with or without renal failure (a simple statement of serum creatinine in the patient example) will have different requirements for dosing with digoxin, gentamycin or lithium. Altering the age of the patient from adult to child brings in dose calculation by age or by weight. Another major variable which can be introduced into a problem is pregnancy (see next example).

Example A 23-year old woman has had three witnessed grand mal convulsions. No lesion is demonstrated after full investigation. There is a strong family history of epilepsy.

This problem is straightforward, but may be complicated by oral contraceptives if she is taking them, which may lead the group to a prescription for phenytoin. Now add pregnancy to the case:

Example A 23-year old pregnant woman has had three witnessed grand mal convulsions. No lesion is demonstrated after full investigation. There is a strong family history of epilepsy.

Immediately the problem is complicated by risks of teratogeneticity of the varying available anti-convulsants. In the Guide to Good Prescribing a set of P-drugs is generated for a particular condition suitable for the straightforward management of the uncomplicated patient—the treatment of first choice. Within a training course, a first set of patient scenarios should probably illustrate this fact and make the point that many patients can normally be treated with first-choice drugs.
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Teacher’s Guide to Good Prescribing

However, specific patient factors (age, organ functions, pregnancy, other diseases, other drugs) may dictate a shift away from the P-drugs for the condition. This can be illustrated by the more complicated examples mentioned above. Such scenarios may lead the discussion to drugs normally accorded a lower priority (“second choice”) for the condition. In constructing the patient problems you can choose where the emphases will fall, enabling you to illustrate the difference between P-drugs and patient drugs—those suitable for a more complicated individual. In summary, very small changes to your patient’s age, pre-existing disease, other drug therapy and reproductive state can bring profound differences in the flow of a tutorial, and in the therapeutic decisions taken in the end. By such simple means the tutorial can be adapted to the learning objectives of the session.

Step C. Modify a clinical scenario to emphasize problems in patient understanding or compliance
All the illustrations above deal with the safety or efficacy of prescribing drugs in special circumstances. The principles are medical or pharmacological. However, the Guide to Good Prescribing goes further than just writing a prescription: it also deals with the interaction between prescriber and patient. At this point it is possible to modify the clinical scenario to illustrate some of the more difficult aspects of guaranteeing patient understanding or ensuring adherence to treatment. If you make your patient developmentally disabled the students must think of ways of ensuring regular drug taking. If you make your patient deaf the students must find ways of communicating (this situation can be particularly stressful for the student if you use roleplay for this part of the tutorial). If you make your patient old and forgetful, the consideration of the likelihood of adequate compliance becomes far more important than the earlier consideration of drug choice. There is an unlimited number of possible combinations.

Step D. Rehearse your clinical scenario
Once the clinical scenarios come together, rehearse in your mind the way in which the tutorial will run. As you have constructed a patient problem, you will need at some point to test the suitability of the student group’s P-drug for the patient in your clinical scenario. This assumes the group has already developed a P-treatment or a list of P-drugs for this condition. Alternatively, if the group has not (yet) developed a P-treatment for this condition, the patient problem could first be used as the reason to generate such a Pdrug. In that case verify during the discussions that the patient scenario is actually representative for the “normal” case for this condition. Jot down the major discussion points that you think your patient problem will raise. Do you need any resources specifically for this problem (for example, articles about drugs in pregnancy or renal disease, or drug interactions)? How does this patient problem fit within the overall prescribing course? What are the key points that you want to bring about through this clinical scenario? In short, what are your learning objectives for this scenario? Finally, check the problem against the understanding of a critical colleague. Is it credible, true to clinical reality, illustrative of important points for student learning, and logically placed in the development of your curriculum?
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Chapter 3. How to construct good patient examples

Summary: practical points for constructing a patient scenario
• Make sure the focus is on therapy and not on diagnosis • Start with a simple case where the P-drug can be used • Modify the scenario to bring about special teaching points in drug choice • Modify the scenario to emphasize problems in patient understanding or compliance • Always rehearse your clinical scenario

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Teacher’s Guide to Good Prescribing

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Teacher’s Guide to Good Prescribing

CHAPTER 4

Teaching notes for the Guide to Good Prescribing he objective of this chapter is to summarize some of the experiences of teachers who have used the model of the Guide to Good Prescribing in both traditional and problem-based learning curricula. It provides you with some basic ideas and examples to stimulate you to develop your own teaching programme. Most of the examples in this chapter originate from problem-based training courses and are therefore presented in the form of a patient problem. However, they can be adapted to the setting of more traditional curricula.

T

Teaching notes for Chapter 1: The process of rational treatment
Chapter 1 is intended to provide the reader with a brief overview of the method. Although only five pages long, it introduces key concepts that are dealt with extensively later in the book. These key messages are that: • the process of treating a patient follows a systematic methodology • rational treatment is based on a thorough understanding of the patho-physiology of the disease • treatment options can be divided into the following types: 1. advice/information 2. non-drug treatment 3. drug treatment 4. referral • there are two stages in treating a patient: 1. choosing a P-treatment and P-drug(s) for common conditions and complaints 2. the six-step routine in treating a patient. The chapter is often used as introductory reading material to a course in pharmacotherapy. In such a case, care should be taken that students extract the key concepts of this chapter. Many students may respond to the question “What was the subject of the chapter?” with “The treatment of dry cough”. As a general introductory classroom session you may present the following assignment:

Suggested student assignment Many of you have visited a doctor. List chronologically and along general lines the process that was going on in the doctor’s head during the consultation. Try to subdivide broader issues, such as examination, into logical parts (physical examination, laboratory examination). 21

Teacher’s Guide to Good Prescribing

To increase awareness of the methodology, one or more homework assignments may accompany the reading of the chapter. A few examples of such homework assignments are given below. In a subsequent classroom session the homework assignments may be used as starter questions for a group discussion.

Suggested student assignments 1. Identify three key concepts in the process of rational treatment. 2. Summarize the treatment of the patient with dry cough in a flow chart, identifying the different steps and actions taken. 3. After reading Chapter 1, construct an example of rational treatment, choosing one diagnosis from a short list of current topics for the students. The easiest way is to start with a patient with a single diagnosis. 4. Which steps would change if the patient was a 5-year old girl with the same symptoms of dry cough?

Teaching notes for Part 2: Selecting your P(ersonal)-drugs (Chapters 2 to 5)
General difficulties with this section
At first, most students are easily confused by the P-drug concept. One of the most common mistakes is that they think that P(ersonal)-drugs are drugs personal to the patient, rather than personal to the doctor. As a consequence, when they start treating individual patients in a later stage of the programme, they want to start again with the process of choosing P-drugs for that patient, rather than just checking the suitability of the P-drug they had already selected for this condition. Another problem is that the P-drug concept may not get across: a P-drug is not the name of a group of drugs or of a single drug. It is a drug that is ready for action: a drug treatment of first choice with its strength, dosage form, duration of treatment and necessary warnings and information to the patient. It may be good to stress the concept of Ps A P-drug is a drug treatment here. If this concept is not made clear, students ready for action may again start choosing a P-drug at the moment of treating patients. The phrase “ready for action” is known to be very helpful in clarifying the P-drug concept. Students often lack detailed knowledge of the condition or disease they are discussing, and of the properties of the related drugs and drug groups. At an introductory stage this is not a problem but rather an opportunity for the students to learn to access the literature. It is good to anticipate this lack of knowledge and to help the students to seek answers to the problem. A typical strategy in problem-based learning is to identify a number of gaps in the knowledge of the group and to have pairs of students find the answer and report back to the group. Usually they cannot do this within one setting. The tasks may then be given as an assignment for homework. The more conventional solution is for the teacher to identify certain parts of books or articles where the students will find the answer, and give them a certain limited time to do it. However, the students will not actively learn to find the relevant information themselves by this method. It is therefore not recommended.
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Chapter 4. Teaching notes for the Guide to Good Prescribing

Step i. Define the diagnosis
The essential part of this step is to (re)define the diagnosis for therapeutic purposes. It is very common for the next steps in the process to be frustrated because students are unaware of the meaning of this first step. In addition, defining the diagnosis is often hampered by students lacking knowledge of the specific condition. Both problems should be recognized at an early stage and immediate measures must be taken. For example, the students could choose a diagnosis they are familiar with, rather than being forced to work with the one in the book; or the session could be postponed to allow them more time for catch-up reading. Another approach may be to define the diagnosis as part of the problem. For example, the assignment may read “Choose a set of P-drugs for moderate essential hypertension (diastolic pressure 105–125 mm Hg) without signs of end-organ damage”. During the classroom session or in subsequent assignments the subject may be broadened as follows: “Choose a set of P-drugs for severe hypertension due to renal artery stenosis and for mild hypertension due to pre-eclampsia”. It is a good idea to start with the moderate variant, as the drug groups included in the P-drug list will most likely be considered in the mild and severe variants as well.

Suggested student assignment Consider the indication asthma for which you want to choose P-drugs. How many different types of asthma would you consider for therapeutic purposes? Also include categories for patients from high-risk groups, if appropriate. Comment: Asthma is a good example because the students should end up with at least five different diagnoses, depending on their way of classification: mild/moderate/severe, asthma in children, with/without infection, hyperreactive/allergic, status asthmaticus, acute attacks, exercise-induced.

Step ii. Specify the therapeutic objective
Students (and many teachers!) tend to specify the objective of treatment in too vague terms such as: relief of the symptom, or reduction of a parameter. However, the amount of effect and the time to achieve it should be specified as much as possible. For example, in case of moderate essential hypertension the therapeutic objective “get the blood pressure back to normal” is too vague. Instead, it may read “to prevent end-organ damage and normalize life-expectancy by reducing (within one month) and maintaining the diastolic blood pressure under 90 mm Hg”. This example also shows that there are at least two endpoints: blood pressure and end-organ damage! During the process the term ‘end-organ damage’ will have to be defined, which often requires self-study by the students.

Suggested student assignments The indication is bacterial pneumonia (temperature: 39.6 ° C, moderate dyspnea). Specify your therapeutic objectives for choosing one or more P-drugs if this indication concerns: • children under 5 years of age • adults of 20–40 years • adults older than 70 years.

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Teacher’s Guide to Good Prescribing

Step iii. Make an inventory of effective groups of drugs
Making the inventory of effective groups of drugs is usually not a problem. Do not delete ineffective drug-groups by yourself (although you may be tempted to save time), but let the students go through a process of considering and weighing a drug-group that is for some reason of no use in therapy. This experience will contribute to their understanding of the process.

Step iv. Choose an effective group according to criteria
This step is a difficult one for students to take. At this point in the discussion some students are usually confused by several questions: which criteria should be used, how does one assign weights to various pieces of evidence, and where can the necessary information be found? Weighting the various pieces of evidence is at the very heart of choosing a P-drug. Many teachers choose to teach this aspect by discussing an analogy with a subject close to the student’s mind. Examples are: choose a destination for your next holiday, choose a car, or a dinner to cook. Such subjects guarantee a lively discussion and are ideal for students who are not very familiar with group work. However, if the students are more experienced with problem-based learning you may choose a less familiar topic. This approach has the advantage that the students are less able to solve the problem quickly by relying on their problem-solving skills without struggling with the choosing process. A possible assignment could then be to choose a household product on the basis of three different advertisements. Another method to weight different pharmacological group options is the multi-attributive utility analysis (MAUA). In brief, the available drugs or drug-groups are listed and scored according to four criteria: efficacy, safety, suitability and cost. The average score for each option is calculated. The scores determine the ranking order of the alternatives. The importance of specific weighting criteria may be enhanced by attaching weighting factors to them. For example, for the treatment of an acute severe illness, such as a heart attack, efficacy bears more weight than safety, suitability or cost. The weighting criteria could then be set at 0.4 for safety and 0.2 each for the three other criteria, or even 0.7 for efficacy and 0.1 for the others. The weights should always add up to 1. There are also other ways of ranking the groups. One alternative would be to create a table of the various drugs and the four criteria, and give positive and negative points or plusses and minuses to the various criteria for each drug. Another way is to list for each drug the positive aspects (e.g. effects) and negative ones (e.g. side-effects) without attributing any value to them.

Suggested student assignment Determine the weighting factors for the following indications for efficacy, safety, suitability and cost: • Moderate hypertension in a person aged 30–45 • Moderate hypertension in a person aged 30–45, with signs of end-organ damage • Moderate hypertension in a person aged 70 • Moderate hypertension in a pregnant woman Explain the differences, or why no differences are present.

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Chapter 4. Teaching notes for the Guide to Good Prescribing

MAUA visualizes the choosing process. Students become aware of the use of different criteria to weight. Gaps in their knowledge are easily identified by themselves or by the tutor. Usually MAUA stimulates lively group discussion. It has, however, a number of pitfalls: • Students who cannot think schematically do not grasp the method instantly. It is advisable that the process of MAUA is learned first by using the everyday examples of choosing bicycles, cars or food, or using very easy indications (e.g. iron deficiency anaemia). Do not introduce weighting factors until the choosing process has been completed. In the first round it is perhaps easier to use + and - scores only. • Students do not understand the criteria. This situation occurs frequently, especially with ‘suitability’. Although this criterion is discussed on page 24 of Guide to Good Prescribing, it still may not be clear. Most students feel that the convenience of a dosage form is to be scored under suitability, but many argue that an inconvenient dosage form leads to less efficacy and should be scored there. You may take two approaches to this problem: the typical problem-based learning (PBL) approach would be to let the students themselves define which aspects are to be scored under which criterion. Alternatively, you may define yourself what is to be scored where (see next point). • Students are not capable of identifying meaningful scores for the different criteria. Therefore, most of the groups tend to use non-numeric scoring (±, +, -) rather than numeric scoring (0–10), which hampers the application of weighting factors. In this case, students should find the answer to the question of how to convert non-numeric scores into numbers. • However, the heart of the matter is that students have not developed a perception of the difference between a score of ‘6’ or ‘7’. Indeed, this lack represents the major weakness in using the MAUA (would you know how to score efficacy of aspirin for moderate tension headache? 4, 5, 6, 7, less, more?). Using the MAUA over the years has provided some solutions, e.g. to score efficacy, you imagine 100 patients and estimate the number of patients in which you would reach your therapeutic objective given that 100% of the patients comply with the therapy. If literature shows that a certain drug is effective in 58% of the patients, the score on efficacy may be 6. Similarly, to score suitability, estimate the number of patients who will not discontinue the therapy due to interactions, contraindications or problems with convenience of dosage form or schedule. To score cost, the price of the total treatment should be calculated, rather than the costs of a single dosage form. It is often advisable to use predefined ranges of costs per year or cost per treatment period and attach scores to them (e.g.