Thursday, 27 November 2008

Applied Pharmacology - time to change the way of training

Dear Bloggers

One of my significant concerns with instructing junior doctors is their paucity of knowledge and application of learned pharmacology in clinical practise.

As a medical student I learned about the in-depth aspects of the major drugs e.g. beta blockers, loop diuretics, antibiotics etc, which included their absorption, bioavailibility / distribution, detoxification and elimination in addition to drug interactions and major side effects. I learned many of the drugs in respect of their generic name which in practise makes it much easier to identify a class of drug and the potential side effect profiles.

This background provided a very good foundation before actually prescribing and using drugs in the clinical setting.

It is not simply good enough to train in basic pharmacology as we as doctors are prescribing medications everyday to our patients and we must understand the drugs with the desired and undesired effects.

In my opinion, having trained newly qualified doctors straight out of the many medical schools throughout the nation, there appears to be little requirement for detailed pharmacology knowledge. Surprising to me when I first started teaching in Japan, I found that drug names are remembered and prescribed via their trade name. Of course, using trade names of drugs is okay if everyone around knows the unique trade name, but for purposes of international communication, generic names are used predominantly in other countries. One reason for the use of generic names is to reduce the confusion over the many thousands of drugs that exist.

This current situation cannot be good for the doctors training or for the patients who rely on the doctors knowledge to prescribe the best, evidence based drugs at the least of cost.

So, what can be done to improve the knowledge of junior doctors pharmacology?

Well, it all has to do with the adequacy of training. More intensive lectures on pharmacology at medical school with focus on their clinical use and polypharmacy (use [overuse] of drugs in combination) and potential side effect profiles. Such lectures should be actually given by doctors who have used the drugs and who can truly give a ground based opinion on their use rather than regurgitating what is written in a dusty old textbook without ever having used the drug before. One such misunderstanding of drugs has resulted in the under use of amiodarone for the fear of long term side effects despite the brilliant rhythm control properties over other anti-arrhythmic drugs.

Pharmacology testing should be made a higher priority for examination purposes in the National Examination but particularly in the context of clinical use.

Moreover, the old way of senior ordering junior doctor to prescribe drugs without explanation should now be supported with evidence that such a drug works and that it is effective more than other drugs in any particular clinical scenario in order to appropriately teach the junior doctor. Evidence based practice is not just knowing a list of papers, it is knowing how and when to apply the evidence and knowing when there is a lack of evidence in support of any particular drug.

Eminence Biased Medicine has to morphologically change to become real EBM in order for medicine to be totally free from clutter of the yesteryear pseudo-leech treatments that were prescribed to treat all ailments but did little to do anything except to show the patient that the doctor was actively doing something.

At the end of the day, it comes down to training physicians to become physicians rather than training them to pass exams. Of course, we must all do standardised examinations to become doctors as there has to be a minimum basic standard, but with a change of emphasis and intensive pharmacology training, the new doctors coming through training would have a much better understanding of how to treat disease, both effectively and safely.

If you are interested in basic and advanced pharmacology, I would advocate the use of several pharmacology books which include:

  • Rang and Dale's Pharmacology - Rang, Dale, Ritter and Flower, 6th Edition. Churchill-Livingstone publishers. This book is very detailed and provides a deeper background to the understanding of drugs and their actions. I used an earlier edition at medical school to supplement my lecture notes and develop a wider understanding of all the drugs I needed to know.
  • Clinical Pharmacology and Therapeutics (lecture notes) - Reid, Rubin and Walters. Blackwell publishing. Again, I used an earlier edition of this book to learn the relevance of drugs to clinical practise as a medical student. It gives condensed information about the use of drugs.
I would highly recommend both books. I have no vested interest in recommending these books as it is my wish only to improve the standard of doctoring in general.

In order to be good, safe and knowledgeable physicians, we need to know our 'bread and butter' basic medicine before we can progress to the triphasic CT scan and PET scanning modalities that are looked upon so highly, yet have little to do with everyday practise. Without a good knowledge of drugs we are doing ourselves as physicians a great disservice and that of our would be patients.

Please consider....