‘Prescription talk’ - Preparedness of Indian medical graduate to prescribe and communicate

INTRODUCTION

Prescriptions are the most frequent medical intervention, following which patient counselling done by healthcare providers leads to enhanced medication education, which results in improved patient adherence.^[1,2] Poor medication adherence is an essential global problem and is often because of poor communication between physicians and patients.^[3] Patients who received face-to-face education about their prescribed medications demonstrated significantly better medication adherence and higher satisfaction levels compared to those who received limited information or tele-education.^[4] Research showed that prescribing errors were the most prevalent, reported in up to 91% of prescribed medications, with dosing errors specifically occurring in up to 41% of cases.^[5]

Medical graduates need to learn communication skills as a core competency according to the regulations established by the Medical Council of India through their 1997 Graduate Medical Education guidelines^[6] and recently, the National Medical Commission (NMC) also released the guidelines for Prescription in Professional Conduct Regulations (2022).^[7] Communication skills which was just a desirable attributes has evolved to be an essential competency.^[8] Medical graduates must demonstrate competency in their prescription abilities to deliver instructions for patients, along with caretakers, along with reviewing of safety warnings for prescribed drugs.^[6]

Patients rely on physicians as their main source of medical information for learning about medication risks, while also discovering adverse drug reactions (ADRs). Research indicates that discussions about risks and adverse drug events occur in <30% of patient–healthcare provider interactions, which leads to dissatisfaction or non-compliance with medication therapy.^[1]

The ineffective medication prescription communication was caused by healthcare practitioners using medical jargon and their inability to deliver prescriptions in simple language, while also failing to listen actively or help patients respond.^[6]

Learning styles among students differ significantly when it comes to acquiring communication skills.^[8] Multiple teaching approaches utilising experiential methods such as role-plays and patient tracking along with simulations and small group discussions have been developed for communication skill training, and role-plays emerged as the most popular method.^[6] Students are able to realise the deficits of safe drug therapy during this simulated patient-based learning.^[9]

Despite having plenty of complaints and litigations due to issues in communication skills, it was never considered for the comprehensive training.^[8]

The essential skills of prescription talk are imbibed in the 2^nd Bachelor of Medicine, Bachelor of Surgery (MBBS) curriculum. The Competency based medical education (CBME) curriculum expects the Indian medical graduate (IMG) to retain and perform all the skills in real life situations. However, there may be an expected decay of skills over a period from the 2^nd phase to internship and further as an IMG. Hence, this study was conducted to assess the retention capacity and how it can be improved with reinforcement during the internship.

MATERIALS AND METHODS

Data collection procedure

The demographic data related to age, gender and the clinical postings were collected. Participants were first sensitised to the study by briefing all the components.

Baseline scores were collected on the day of enrolment to assess the completeness of prescription writing by objective structured practical examination (OSPE); participants were made to write prescriptions of their choice, which were recently written during clinical postings, and this was analysed for completeness (score of 10).

Similarly, baseline scores were collected for communication skills by objective structured clinical examination (OSCE); non-teaching faculties who are trained as simulated patients were utilised for communication skills for the 3 components (score of 10 each). For acute conditions, the same prescription was utilised, whereas for chronic conditions, choice was provided with ready prescriptions like diabetes, hypertension, tuberculosis and epilepsy. Of the multiple devices, the metered-dose inhaler was selected. The observers recorded the scores using a checklist. The researcher was not a part of the data collection to avoid bias. The method is represented schematically in Figure 1.

Close

Figure 1:

Flow chart showing the method of conducting the study.

Export to PPT

To assess the preparedness, the global scores with the predefined criteria of <50% (unsatisfactory), 51–70% (needs improvement), 71–90% (satisfactory) and >90% (exceeds expectation) were adopted.

After 15 days, all the participants were trained by the faculty for ideal prescription writing as per the NMC and role-play as per the checklist for all three components of communication skills. OSCE and OSPE were repeated for the post-test scores.

Confidence levels were self-assessed at baseline, after pre-test and after post-test on a 3-point Likert scale. During the study period, care was taken to maintain data privacy and confidentiality measures.

RESULTS

Among the 33 participants enrolled in the study, males were 8 (24.2%) and females were 25 (75.8%). They all belonged to a single batch of CBME with an age range of 22–25 years. Most of the participants had completed 6 months of internship and the major postings. There was no significant difference between genders in pre- and post-test scores as shown in Table 1.

As per the predefined criteria, the global scores in 75.76% of the participants at baseline were not up to the specifications of IMG and needed improvement, which shows that the retention skills over a period from 2^nd MBBS to internship are poor. Demonstration improved this to a satisfactory level following the intervention and role-play to 93.9%, which is statistically significant as shown in Table 2 and Figure 2.

Close

Figure 2:

Comparison of scores pre- and post-intervention.

Export to PPT

We considered four components as part of the prescription talk in the study. We found a significant improvement in prescription writing after intervention with the demonstration technique. Similar improvement were also observed for the communication skills with role play as shown in Table 3 and Figure 3.

Close

Figure 3:

Confidence level of participants on prescription talk.

Export to PPT

We also assessed the confidence levels for prescribing and communication using a Likert scale, which also improved following the intervention, as shown in Figure 3.

DISCUSSION

The traditional curriculum focused primarily on knowledge acquisition with a bit of skills without touching on soft skills which are not sufficient to provide a holistic healthcare as a doctor of first contact. A medical student can access multiple competency domains that integrate knowledge combined with communication skills in various social and cultural contexts after the adaptation of CBME.^[10]

The CBME curriculum, which is an outcome-based curriculum, is expected to have the first batch of IMG. Measuring the outcomes of these roles is practically impossible; hence, we took doctor–patient interaction, especially in the second half of the consultation – prescription talk, which is most essential for an IMG. The pre-test scores at baseline were considered the preparedness of IMG for prescription talk. The global scores in this study were between 50 and 70% (needs improvement) in 75.76%, which shows underpreparedness. Following intervention, it improved to 70–90% (satisfactory) in 93.9%. This shows that the decay of skills can be refreshed by incorporating these skills as part of an internship. There was no difference in pre- and post-test scores between genders. Research reveals that junior doctors’ awareness of essential pharmacological proficiency for proper drug prescribing remains insufficient.^[11]

Prescription writing which is a certifiable skill in 2^nd professional needs to maintain the proficiency till internship and as an IMG. However, in this study, the scores were 6.0 ± 1.9 out of 10 at baseline, which is not satisfactory. They were poor at mentioning the doctor’s details completely, including the date. The drugs were also not written in generic names and uppercase, and the instructions to pharmacists and patients were missing, which were poorly legible. This was similar to a study conducted on prescriptions. [12] The reinforcement was planned with the help of the demonstration session, which improved the scores to 8.1 ± 0.8, which is statistically significant. These types of studies are conducted more on students than interns, with similar results in one study^[12] and better results in another study.^[13] The challenges are taken care of in the curriculum design,^[13] but still feel yet to be accomplished.

A good communicator is one who can convey the information written on the prescription effectively to the patient, which can improve treatment adherence and prevention of adverse effects. In this study, we decided on OSCE for 3 conditions: Acute or simple, chronic condition and explanation of the device metered-dose inhaler (MDI) with the help of an observation checklist.

The patients usually want to know about the condition they are suffering from. Hence, during a talk on prescription, it is ideal to explain the symptoms/disease, the drug’s indication, route, dose, method of administration, duration, ADR and precautions to be taken. This is followed by summarising and reconfirming whether the instructions are clearly understood through questioning. The scores improved from baseline of 5.7 ± 1.5 to 7.1 ± 1.0 after role play which was statistically significant. Very few explained the ADR and precautions. The concerns, understanding or summarising were poorly done. This shows there is a decay of skills over time and can be retained with reinforcement at regular intervals. Similar results for role-play were observed, and the participants also gave positive feedback on the session.^[13,14]

Chronic conditions require treatment for long periods, which are associated with ADR and drug interactions, leading to poor adherence, affecting the outcome. They were poor at explaining the drugs and non-pharmacological management. Information has to be provided about the sequel of disease and drugs to improve patient compliance, which was not addressed adequately. These lacunae were attended by giving feedback and a role-play, which improved the scores from 5.2 ± 1.4 at baseline to 7.3 ± 1.0. This can be much better with peer role-play.^[15]

Plenty of devices are prescribed to the patient without or with no clear instructions, again leading to therapeutic failure. In this study, we checked the skills for MDI, which is commonly used by bronchial asthma patients. The scores were reasonably better when compared to the other two conditions. It was 7.0 ± 1.6 at pre-test and improved to 8.3 ± 1.0 following intervention, which is statistically significant. The skills were poor in studies conducted on medical students, which are exhibited in patients also.^[14,16,17]

Normally, the confidence of the interns should be high, as they have cleared their qualifying examinations. However, in this study, we assessed at three levels and observed that only 18% were highly confident at baseline but increased to 66% after intervention, which was statistically significant. The study conducted in Sweden also had confidence levels of around 45% in medication reviews, which increased on repeated reviews.^[18]

By observing these facts with a few participants, the preparedness of IMG for one of the important skills of prescription talk appears not satisfactory. The confidence levels were also not high. Regular training is necessary to attain the proficiency in skills of prescribing which can enhance the confidence. This suggests the need for incorporating it as a part of internship training before they are ready to practice.

CONCLUSION

The low scores in the pre-test indicate that preparedness is not adequate, showing poor retention or decay of skills from the 2^nd MBBS towards internship in both prescribing and communication of prescription. The wider gap between the time of training and its application could be one of the causes. This can be improved with regular reinforcement and assessment during the clinical years of the 3^rd MBBS and regular training during internship.