The pen is mightier than the sword. Reinstating patient care as the object of prescribing education

Abstract

Prescribing (writing medication orders) is one of residents’ commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients’ needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to ‘pre-prescribe’ (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students ‘knotworked’ within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Keywords:

• Activity theory
• prescribing education
• preparation for practice
• workplace learning

Acknowledgements

We thank Drs Samantha Smith and Effie Dearden, and Professor Helen Cameron of the University of Edinburgh for introducing us to pre-prescribing and Dr Ruth Kinston and Professor Andy Hassell for inspiring us to adopt it and supporting our implementation of it. This work would not have been possible without the active support of clinical academic leaders, who are too numerous to name individually, but gave unstinting support to the process of change.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Hannah Gillespie

Hannah Gillespie, BSc, BM, is a junior doctor. As an Academic Foundation Trainee in Northern Ireland her research has focused on medical students’ workplace learning.

Eleanor McCrystal

Eleanor McCrystal, BSc, is a fourth - year medical student at Queen’s University Belfast. She is currently pursuing an intercalated BSc in Medical Science.

Helen Reid

Helen Reid, BM, PhD, is a General Practitioner. Her research interests concern assessment and healthcare workplace learning (particularly in community contexts), drawing on a range of critical methodologies.

Richard Conn

Richard Conn, BM, PhD, is an Academic Clinical Lecturer at Queen’s University Belfast, and a Specialty Trainee in Paediatrics in Northern Ireland. His research aims to promote safer practice by investigating how medical students and healthcare professionals learn in clinical workplaces.

Neil Kennedy

Neil Kennedy, BSc, MB, is a Consultant Paediatrician and Director of Medical Education in Queen’s University Belfast. He returned to Northern Ireland in 2016, after practicing and teaching in Malawi, as Dean of the Medical School.

Tim Dornan

Tim Dornan, DM, PhD, is an internist and endocrinologist who completed a Masters and PhD in medical education at Maastricht University. His primary methodological interests are qualitative and implementation research. He is Professor of Medical Education at Queen’s University Belfast and Emeritus Professor, Maastricht University.