Preparing to prescribe
Lessons from the prescribing safety assessment
In 2014, most medical students graduating in the United Kingdom sat the prescribing safety assessment (PSA) for the first time. Some medical schools even started to use it as a component to determine students’ finals results, and it is envisaged over time that the exam will take more prominence in the formal assessment of medical students. The results of the first sitting are in, and we look at how the assessment went and why it was introduced and ask whether it will achieve its aim of making graduates safer prescribers when they arrive on the ward
About the prescribing safety assessment
The assessment examination is run jointly by Medical Schools Council Assessment and the British Pharmacological Society. It has been piloted since 2010, but 2014 was the first year that all final year medical students could take part. Although not currently mandatory at a national level, more than 7100 final year students sat the two hour online assessment last year.
The Medical Schools Council says it envisages that the PSA will become compulsory for all new foundation year 1 doctors in future, although at present the examination’s status is at the discretion of the medical school. For some of those students, the examination will contribute to their final degree result. These students will be required to pass the PSA before graduation. For others, the examination is formative, and they may not be required to pass.
A list of medical students who passed the PSA will be provided to foundation schools when they graduate and start their careers as junior doctors. Students who do not pass or sit the PSA may be asked by their foundation school to take the test.
Research in 2009 showed that about 9% of NHS prescriptions written by newly qualified doctors included some kind of error, ranging from the trivial to those that could cause patient harm. The PSA (formerly the Prescribing Skills Assessment) was introduced in part to reduce the numbers of prescribing errors. The PSA’s development represented a recognition that prescribing is a complex and difficult skill to learn and that many new doctors felt underprepared for the task.
Simon Maxwell, professor of pharmacology at the University of Edinburgh and medical director of the PSA, said that junior doctors write “a surprisingly large proportion” of the prescriptions in NHS hospitals and that there had been “concern” from both universities and hospitals about how well prepared they were. He said that junior doctors write between 10 and 50 prescriptions each day, and may prescribe around 200 different items over the course of their foundation training.
The assessment was developed to enable graduates to demonstrate “minimal acceptable safe practice” and is set at a level appropriate for final year medical students, he said.
The problem with prescribing
Why do junior doctors struggle with prescribing, now that there is so much guidance from the National Institute for Health and Care Excellence and other bodies about which drugs should be used? As Maxwell points out, it is a complex skill to master, complicated by the aged and multi-morbid population many juniors will meet in hospital.
“As a prescriber you have to choose a drug, a dose, a route of administration and frequency over time. You have to do that in the face of many different variations such as age, sex, genetic make-up, potentially interacting diseases, and other drugs which might have an influence. Then you go on to counsel patients effectively about the medicines they are taking and work out a sensible monitoring strategy, because you can never be sure what will happen when you write a prescription,” he said.
In addition, NHS trusts around the country have different prescribing documentation—“clearly an unnecessary challenge for prescribers”— and e-prescribing has not arrived in many places. Even with e-prescribing, the challenge of meeting the needs of the individual remain. “There will always be a need for individuals to be well trained and with good judgment about how to use medicines,” said Maxwell.
Anna Ffrench-Constant, a foundation year 2 doctor working at University Hospitals Bristol NHS Trust, took the PSA in 2013. She said prescribing as a newly qualified doctor is “pretty scary to start with.
“The main thing was having the confidence in picking the right drug. The initial things we prescribed were painkillers and anaesthetics and so on. I would ask someone to check what I was doing. It was slow starting but you need to ask advice about what to prescribe,” she said.
Results of the 2014 assessment
The pass rate from the 2014 assessment was 94%. Maxwell said: “We thought that was a pretty good result. We would like it to be 100% but that indicated to us that performance was increasing [from 2013] because it was a more stringent test this time around.”
He said the assessment was marked “almost instantaneously” through an automated system but that all responses are reviewed by assessors in case any correct answers submitted had not been included in the marking scheme. The results were published within a few days and there had been no reports of technical problems with the assessments.
Maxwell said the organisers believe that the assessment had increased the focus on prescribing as a skill during training. He said that there is “some degree of variation between [the pass rate at] different schools but that has to be taken with a pinch of salt . . . I think it’s too early to say if there is any cause for concern. Inevitably there will be some variation but I don’t think it will last very long.” He declined to say which schools had done better or worse.
He also refused to be drawn on whether students performed better or worse on certain sections of the examination, which is divided into eight areas. “We haven’t seen enough to know if there are systematic problems in one particular area,” he said.
Students are asked for feedback on the exam, which Maxwell said had been overwhelmingly positive. The main gripe is the amount of time allowed to complete each question. Students must complete 60 items in 120 minutes, which many found a challenge. Despite this, Maxwell said, “The students are remarkably on side. Despite the fact it’s an extra hurdle, we don’t get anyone saying it’s a waste of time. They recognise that prescribing is a challenge for them: it has been a concern and they are pleased there is something that is driving this forward. We’ve had a lot of positive comments about what’s happening in different medical schools [in terms of training].”
Effect on practice
The PSA was developed to reduce prescribing errors. But how will the success of the scheme be monitored to see whether this has worked? It would be interesting to see a repeat of the 2009 research in a few years’ time to see whether the error rate has reduced. If the need to get students through the PSA means that medical schools increase their training on prescribing, that can only be a good thing. But it’s difficult to show that the introduction of an examination translates directly into safer prescribing.
“This is a very challenging research project,” said Maxwell. “There will be opportunities if the appropriate approvals can be gained to anonymously link what happened in PSA to clinical variation, looking to see if poor performance at PSA can be linked to sub-optimal clinical events.”
So does preparing for, and taking the PSA, help new doctors on the wards? David Houghton, a foundation year 1 doctor who trained at Hull York Medical School, sat the exam in 2014. He said that the school had provided regular prescribing education sessions in his final year, using marked up charts and patient examples, with a focus on higher risk drugs such as insulin and warfarin, “stuff that a lot of juniors might find a bit troublesome to start with.”
He said that the impact of having studied for the PSA was “huge” when it came to starting work on the wards. “I started on a weekend and nights, so I was really thrown in at the deep end. During the day there are lots of people around to ask for advice and help but at night you are on your own. I found myself more comfortable with routine prescribing [because of the exam]. If you’re familiar with that, it makes your job a whole lot easier.”
Houghton added: “It’s about being prepared as much as possible for starting work. It’s a big step from being a medical student to a junior doctor. In terms of making your life easier, being familiar with routine drugs, it makes a huge difference. You’re safe knowing that what you’re prescribing is right.”
Ffrench-Constant said that taking the PSA in her final year had introduced her to the most useful tools for good prescribing, including the online British National Formulary of drugs (BNF).
“I did find it [the exam] quite interesting and perhaps more helpful than I’d realised. Before then I hadn’t really accessed the online BNF much. I practised using it and had a look at it. I found the way questions were structured in the exam and the fact we had access to it online worked quite nicely and you could search quite easily in a way I hadn’t known about before. I did use it a lot when I started working and still do. It’s much easier and quicker [Than the paper version] to look things up,” she said.
She added that some colleagues who hadn’t taken the exam were unaware of the online BNF and tended to use the paper version because a copy is usually available on the wards. “They can spend ages looking through—not everyone realises you can search for things easily, like the condition, in the online version.”
In addition to the training given by different medical schools, all students can access the sample questions on the PSA website, which show the type of question and the format for answering. Although many hospitals still use paper prescriptions, the examination questions use e-prescription forms to fill in. These may be different from some of the forms seen in hospitals, so it’s worth checking them out.
Houghton strongly recommends taking the mock examination on the website, timing your performance so that you can learn to pace yourself during the real thing. “That was good practice. What a lot of people struggled with if they hadn’t done the mock exam was time—how little time you have per question.”
He also recommended getting to know the layout of the BNF beforehand. The exam is “open book,” meaning you are able to access the BNF to help you answer questions, as you would do in real life. “It’s a good idea to familiarise yourself with the BNF online or hard copy, knowing where things are so you can quickly get to the section you want rather than going to the index every time.”
Student BMJ is running a series on prescribing, with each article focused on one area of prescribing skills, in line with the PSA. You can find the prescribing features on the website at http://student.bmj.com/student/clinicalreview.
The PSA is likely to become an increasingly important part of final year examinations. If it continues to fulfil its role in ensuring that graduate doctors are better prepared for the task of prescribing when they get on to the wards, that can only be a good thing. Prescribing errors can be disastrous for the patient, but also a heavy burden for the doctor.
Prescribing tips for new doctors, from Simon Maxwell
- 1. Learn to find your way around the BNF. I can’t overstate how important that is. Being a prescriber is so challenging: there are so many things to think about. I always go to the BNF to double check that what I have done is correct.
- 2. Find the prescribing documentation used in your NHS trust. It’s not unreasonable to write and say: “I’m about to move to your trust. Could you furnish me with some of the documentation?”
- 3. Look at the “Ten principles of good prescribing” on the British Pharmacology Society website, (www.bps.ac.uk/SpringboardWebApp/userfiles/bps/file/Clinical/BPSPrescribingStatement03Feb2010.pdf)
- 4. Review the 10 most common areas you are likely to be prescribing in and ask yourself how confident you are to deal with those. Some might not be what you’d expect—for example, constipation is one of the things that you’ll prescribe most for, along with pain. Speak to the doctors on the wards and ask what things they get called on to do most.
- 5. Understand the pitfalls of high risk medicine—anticoagulants, insulin, anti-arrhythmic drugs.
- 6. If you are uncertain or out of your depth, ask somebody. The good thing about being a newly qualified doctor is that nobody expects you to know everything and you are still very much in a training role.
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- British Pharmacological Society. Record number of UK medical students take the prescribing safety assessment (press release). 5 December 2014.
- Medical Schools Council. Prescribing safety assessment FAQs for medical students. www.medschools.ac.uk/AboutUs/Projects/Prescribing-Safety-Assessment/Pages/FAQs.aspx.
- Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2008. www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf.
Cite this as: Student BMJ 2015;23:h316