Prescribing - What's all the fuss?

Dr Sepehr Shakib

Reprinted from:
Australian Family Physician Vol. 32, No. 1/2, January/February
2003 • 35

BACKGROUND: Prescribing is a commonly used skill which has until recently been poorly taught in medical school curricula. This is despite the fact that there are a number of proven approaches to teaching better prescribing.

OBJECTIVE: The WHO Guide to Good Prescribing is discussed, with an example elaborating the steps involved in the process.

DISCUSSION: Central to this approach is the development of a rational and evidence based list of P- or personal drugs which the prescriber develops familiarity with and uses regularly for specific indications.

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Have you noticed all the attention being paid to prescribing lately?

There’s the National Prescribing Service, prescribing practice reviews, electronic prescribing, journal articles on prescribing, and the list goes on! What’s it all about?

In fact, prescribing is a big issue. The BEACH data from 1999–2000 showed that at least one medication is prescribed in about 60% of general practitioner encounters, and the overall rate was 110 per 100 encounters.¹ So if you are seeing patients every 15 minutes, eight hours per day, five days per week, in a working lifetime of say 30 years, you are going to write about 250 000 prescriptions! The cost of prescriptions to the PBS was approximately $3.8 billion in 2000–2001.²

Now here is the problem: think back to your medical student training, and try to remember how much time was spent teaching prescribing. For most of us, it was usually a single lecture or two on basics such as: putting the date at the top and signing your name at the bottom. In fact, until recently the majority of medical school curricula have spent less than 1% of total teaching time on prescribing issues, with the majority of teaching time being spent on making a diagnosis.

Unfortunately, many do not appreciate that good prescribing is a skill, and one which needs to be learnt. Teaching therapeutics in medical schools has usually been drug centered, focusing on indications and side effects of different drugs, and prescribing is usually something one picks up by watching the behaviour of others. There has been little focus on the process of prescribing which involves making correct decisions about the choice of medication and individualising it for the patient sitting in front of you. Table 1 lists some of the characteristics of good versus bad prescribing.

In 1994 the World Health Organisation Action Program on Essential Drugs developed a manual on the principles of rational prescribing called the ‘Guide to Good Prescribing’.^3,4 The focus of the manual was on the process of prescribing, and central to it was the development of P or Personal drugs. The rationale being that early in their career, prescribers generally develop a limited set of drugs which they will use regularly from then on.5 By using only a limited number of drugs, they become very familiar with dosage adjustments, adverse reactions etc. This choice however, is often made on irrational grounds, e.g. copying behaviour of teachers or peers without considering alternatives or knowing how to choose between them. Hence, despite the plethora of available antibiotics, most clinicians tend to only prescribe a limited number of these for the common indications, but if asked why they have chosen this particular agent, the answers given are frequently not well founded.