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The theme of the recent joint meeting in Manchester of the Committees of Heads of Pharmacology and Physiology was the teaching of pharmacology and physiology to students of the medical and healthcare professions – is it fit for purpose ?
The stimulus for this topic was a series of articles from leading pharmacologists and clinical pharmacologists questioning the prescribing skills of newly qualified doctors 1,2 and relating this to the reduction in pharmacology teaching which has accompanied the introduction of new teaching methods in medical schools following the adoption of the GMC guidelines set out in ‘Tomorrow’s Doctors’ 3.
To open the meeting, John Rees (King’s College, London) outlined what was expected in terms of medical training. The answer was not merely factual knowledge, which is recognised to be transient, but more importantly the core competencies which will form the bedrock of life-long learning, together with a desire to imbue vision and enthusiasm in students who will go on to practice medicine for the next 40 years. He acknowledged that there was little direct reference to pharmacology in ‘Tomorrow’s Doctors’ although one of the principal declared aims, to accurately work out drug dosage, clearly relied on a good pharmacological foundation.
The extent to which this aim is fulfilled by the time the students qualify was a major point of debate throughout the meeting. The method of problem-based learning focussed on clinical case-studies is now accepted as the norm in medical teaching, but Prof Rees recognised that such learning must be directed by competent staff.
Richard Hays ( Keele University) addressed the question of how current medical training delivers expertise in physiology and pharmacology. His principal thesis was that the design of the medical curriculum should be based on what skills the newly-qualified doctor needs and that this should drive both the learning objectives and the forms of assessment, since students learn for exams rather than for their future professional competence.
To minimise the degree of information overload, particularly in the early stages of the course, he championed the ‘spiral column’ model of learning, in which topics were revisited throughout the course and complexity achieved through layered learning. However, the logistical problems associated with such a course design, and the provision of appropriate teaching staff at each level, were highlighted as major impediments to its successful implementation.
After talks from the ‘providers’, there were then two presentations on behalf of the ‘consumers’. Amy Heaton (4th year medical student at Edinburgh University) reported her findings from an on-line questionnaire completed by 2400 medical students graduating between 2006 and 2008 which revealed a high degree of concern about their per-ceived lack of knowledge of pharmacology. Fewer than 25% felt confident in their ability to accurately calculate drug dosage and write a competent prescription, and over 70% felt that they had received too little teaching specifically in pharmacology.
Whilst this study could be criticised for focussing solely on the shortcomings of pharmacology teaching within the current medical curriculum, it seriously questions whether medical graduates achieve the competencies set out by the GMC, with all the consequent dangers that implies for patient care. Sarah Ross ( Aberdeen University) conveyed similar conclusions from her survey of 64 FY1 doctors of whom 30% described their knowledge of clinical pharmacology as poor or very poor and over 40% claimed that they had received insufficient training in the recognition and avoidance of adverse drug reactions.
The suggestion that prescribing and diagnosis should be undertaken by separate personnel was strongly opposed. It was felt, however, that both sets of data reflected a general unpreparedness in prescribing skills amongst newly qualified doctors which called for a substantial increase in the extent of clinical pharmacology teaching. With the continuing disappearance of clinical pharmacology as a recognised specialty, however, the resource to meet such a challenge is limited.
Focus then shifted to other healthcare professions and representatives of both nursing (Pauline Hood and Simon Kahn, Kings College London) and physiotherapy (Sheila Kitchen, Kings College London) acknowledged the relevance of pharmacology but admitted that there was little specific teaching of the subject in their current training curricula. With the introduction of limited prescribing powers for nurses and potentially for independent physiotherapists, improved understanding of pharmacodynamic and pharmacokinetic principles is essential and attempts to develop such knowledge, particularly via computer-aided learning schemes, were described.
In contrast, Larry Gifford (Manchester School of Pharmacy) explained that almost 50% of the current 4-year pharmacy course is related to pharmacology. In some cases this teaching was undertaken outside the pharmacy department and resulted in comparatively high failure rates, possibly due to being too specialised and unrelated to pharmacy practice. To counter this, IPE (inter-professional education) is increasingly being used to integrate undergraduate pharmacists with trainee nurses and medical students to develop effective health-care teams for the future.
In the final session, Jeremy Ward (Kings College London) considered methods of assessment and how these could be improved. With several medical schools now having an annual intake of over 300 students, it is virtually impossible to use the traditional essay-style examination questions due to the demands that marking makes on staff time. Consequently there has been a shift towards computer-marked assessment using various formats of multiple-choice questions, which are effective in testing core, factual knowledge but require careful design of the questions and post-hoc consideration of the difficulty of the test.
Since, in medicine, the primary goal in training students is not only that they should have adequate knowledge to carry out their roles as junior doctors but also be aware of the limitations of that knowledge (the Rumsfeld conundrum), then the Confidence-Based Marking scheme (http://www.ucl.ac.uk/lapt/) would seem particularly apt. In this case, for every answer students must also give a rating of their confidence of being correct and the marks are then weighted accordingly, the penalty being greatest for an incorrect answer accorded high confidence (the Rumsfeld principle).
A testing method widely used in the USA is Computerised Adaptive Testing (http://www.edres.org/scripts/cat/catdemo.htm) based on Item Response Theory in which questions of known difficulty (calibrated on the basis of the population response) are selectively delivered to students on the basis of their previous answers. Testing continues until the program has identified the ability band of the student with a pre-set degree of confidence.
Whilst attractive in principle, this method can only be used with large student numbers, possibly even on a national scale, as it requires a very large bank of questions and responses in order to achieve effective calibration of question difficulty. However, with current consideration of a national pre-registration exam in medicine (as already applies in pharmacy), such a method may prove appropriate in the future.
To conclude the meeting, Ole Petersen ( University of Liverpool) described his belief in the need for a core syllabus in medical education.
Discussion throughout the meeting had demonstrated the considerable diversity in the teaching of physiology and pharmacology between different medical schools and he therefore proposed a joint working group involving both the Physiological and Pharmacological Societies to develop such a core curriculum. Interested members please contact ebell@physoc.org
Overall, the principal message to emerge from this meeting was that the methods and effectiveness of pharmacology and physiology teaching in the UK is undergoing change and will continue to do so, but the need for that teaching is strong if new graduates in the health-care professions are to be fit-for-purpose.
Martin Elliott
Leicester School of Pharmacy
References
Aronson JK, Barnett DB, Ferner RE, Ferro A, Henderson G, Maxwell SR, Rawlins MD, Webb DJ (2006) Poor prescribing is continual. BMJ. 333 : 756
Aronson JK, Henderson G, Webb DJ, Rawlins MD (2006) A prescription for better prescribing. BMJ. 333 : 459-60
General Medical Council. Tomorrow’s Doctors. Recommendations on undergraduate medical education. (2002)
http://www.gmc-uk.org/education/undergraduate/tomdoc.pdf
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