From learning objectives to student’s competence Transformation into a pharmacotherapy context-learning programme The studies presented in this thesis were performed at the VU University Medical Center Amsterdam, the Netherlands. Three studies, presented in chapter 2-4, were financially supported by grants from the Dutch Ministry of Public Health, Welfare, and Sports (VWS), the Dutch College of Insurance Companies (CVZ) and the Dutch Association of the Research- based Pharmaceutical Industry (Nefarma). Address of correspondence Joke A. Vollebregt Jan van Breemen institute Dr Jan van Breemenstraat 2 1056 AB Amsterdam The Netherlands [email protected] ISBN: 90 6464 650 3 Cover design: J.A. Vollebregt Printed by: Ponsen & Looijen BV, Wageningen Copyright J.A. Vollebregt, Amsterdam, 2004 No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the holder of the copyright. VRIJE UNIVERSITEIT From learning objectives to student’s competence Transformation into a pharmacotherapy context-learning programme ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. T. Sminia, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Geneeskunde op vrijdag 26 november 2004 om 10.30 uur in de aula van de universiteit, De Boelelaan 1105 door Johanna Adriana Vollebregt geboren te Wieringermeer promotoren: prof.dr. Th.P.G.M. de Vries prof.dr. J.C.M. Metz prof.dr. M. de Haan copromotor: dr. J.G. Hugtenburg Contents Chapter 1 Introduction 7 Chapter 2 Learning objectives for undergraduate pharmacotherapy 15 knowledge, skills and attitudes; a national survey Chapter 3 The competence in pharmacotherapy of final year medical 31 students in the Netherlands; a descriptive study Chapter 4 The ability of pre-clinical medical students to learn 47 cognitive pharmacotherapy skills; a controlled trial Chapter 5 Evaluation of the longitudinal context learning programme 65 for pharmacotherapy skills for pre-clinical medical students; a descriptive study Chapter 6 General Discussion 85 Summary 97 Samenvatting 105 Appendix 113 Dankwoord 121 Curriculum Vitae 125 The course of the research project 1995 Study 1: Learning Objectives for pharmacotherapy * 1996 Study 2: Competence in pharmacotherapy * 1997 Study 3: The ability to learn cognitive therapeutic skills * 1998 Preparations for 2nd year context-learning programme (CLP) 1999 Starting 2nd year CLP Preparations for 3rd year CLP 2000 Starting 3rd year CLP Preparations for 4th year CLP and OSCE 2001 Starting 4th year CLP and OSCE 2002 Study 4: Pharmacotherapy context-learning programme 2004 Thesis (* chapters 2-4 are based on the reports written for the organisations who financially supported the studies 1-3 (see page 12 ) 11 CChhaapptteerr Introduction Chapter 1 In recent decades many new potential and effective drugs have been developed and, as a result, more and more diseases can now be adequately treated with drugs. However, the occurrence of adverse reactions may limit the effectiveness of drugs, and may even lead to significant morbidity and mortality rates and increased financial costs. Several studies have shown that adverse reactions can also result in hospital admission.[1-3] A number of adverse drug reactions that can be prevented are the cause of medication errors. Both in general practice and in hospitals, these preventable errors in the prescription of drugs have been shown to include errors in the choice of drugs, the dosage, the form of dosage or the dosage schedule.[4-8] Studies on preventable medication errors A recent literature review on the incidence of adverse drug reactions and outcomes related to preventable adverse drug reactions in hospitalised patients, showed that the median frequency of adverse drug reactions was 1.8%, with a range from 1.3% to 7.8%. The median preventability rate was 35.2%, with a range from 18.7% to 73.2%. Most of these adverse drug reactions occurred in the stage of drug prescription, and were dose-related. Inappropriate drug-prescribing and insufficient patient-monitoring were the most frequently identified causes of preventable adverse drug reactions.[9] In a prospective study performed at a teaching hospital in the UK the causes of prescribing errors were examined, and prescribers who made potentially serious errors were interviewed. The results of this study showed that most of the errors were made because of a lapse of attention or because prescribers did not apply the relevant rules. The doctors themselves also identified many risk factors, such as work environment, work-load, communication within their teams, physical and mental well-being and lack of knowledge. Other factors included inadequate training, low perceived importance of drug-prescribing, a hierarchical medical team and the absence of personal awareness of the errors. It was remarkable that senior house officers and junior house officers made the most errors. All major medical and surgical specialists were represented in this study.[8] 8 Introduction Irrational drug prescribing In addition to the occurrence of serious medication errors, resulting in severe side-effects or hospitalisation, there are also indications that irrational drug prescribing is a general problem in medical practice. Examples of this phenomenon include the prescription of drugs not related to the diagnosis, the prescription of relatively expensive drugs, irrational prescription of antibiotics and unnecessary continuation of drug treatment in the elderly, leading to polypharmacy.[10] Attempts to improve the quality of drug-prescription are partly successful In order to address the problem of irrational drug-prescribing and the occurrence of prescribing errors, several measures have been taken by medical organisations and governments. On the one hand, standards and guidelines for drug treatment have been developed and implemented in the continuing postgraduate medical education with the aim to improve drug-prescription. On the other hand, cost- saving measures have been implemented, for example through the reimbursement system. These measures have contributed to the improvement of the drug-prescription. However, despite these measures medical doctors do not easily change their practice routines including their drug-prescribing behaviour. Examples of reasons are lack of time in a busy practice, patient demands, and the subjective influence of the pharmaceutical industry.[11;12] Medical doctors may not be adequately trained in pharmacotherapy Another plausible explanation for the afore-mentioned phenomenon is that medical doctors have not been adequately trained in rational drug prescribing. [8;13] Education in clinical pharmacology and therapeutics is still not a core element in most medical curricula, and the drug prescribing competence of medical students has rarely been explicitly assessed.[14-16] In the Netherlands, this problem has been the subject of debates since the early nineties. In 1992 the first external review of the entire undergraduate medical training programme was initiated by the Association of Universities in the Netherlands (VSNU). It was concluded that the pharmacotherapy education was satisfactory in only two of the eight medical faculties.[17] In 1993, a committee consisting of pharmacology and pharmacotherapy teachers analysed the pharmacology and pharmacotherapy 9