1. What do Medical Students need to know about Drugs? And how should we assess them? Michael Orme University of Liverpool, U.K. and European Association for Clinical Pharmacology and Therapeutics

2. European Association for Clinical Pharmacology and Therapeutics (EACPT) EACPT was founded in 1993 and runs biennial congresses. 32 European Countries are in membership EACPT Education Sub-Committee started work in 1997

3. European Medical Schools Some 400 medical schools in “Europe” Great variety of administrations and courses. For example Russia

4. Russian Medical Schools Stretch from St. Petersberg to Vladivostok On average each school teaches 200 hours of ‘pharmacology’ ( 50 lectures, 65 demonstrations, 85 hrs of self study) Assessment is by factual recall Elsewhere in Europe ‘hours’ are difficult to calculate and many different curricula exist such as problem-solving or problem based.

5. Importance of Clinical Pharmacology teaching for Clinical Care Case already made by previous speakers speakers! * Thus how should we teach?

7. What Should Medical Students Know About Drugs The idea of a Core Curriculum The importance of Basic Science At Least three approaches Core Knowledge and Understanding An essential drug list ( not WHO ) A Disease Based approach

8. Core Knowledge and Understanding Eg Basic Pharmacology, Clinical Pharmacokinetics Adverse Drug Reactions/ Pharmacovigilance Medication Errors, Drug Interactions, Prescribing for the Elderly /Children Prescribing in Patients with Liver or Kidney disease New Drug Development

9. Core Knowledge and Understanding Core Skills Taking a drug history Drug Allergy Drug Administration Analysis of New data Prescription Writing

10. Core Knowledge and Understanding Core Attitudes A Rational Approach to Drug Prescribing Life Long Learning Risk Benefit Analysis Cost Benefit Analysis Responsibilities of a Prescriber Recognition of the role of other health care workers in the field –eg Pharmacists

12. Core Curriculum Essential Drug List Not necessarily based on WHO system Preparation of a list of perhaps 120 drugs to be known in some detail by students In some case students prepare their own formulary ( eg P drugs ) There will be perhaps 80 or so other drugs the student should be aware of

13. Core Curriculum –Drugs (1) What should the student know about the Core Drugs? Drug Name – generic or approved Drug Class - ?alternatives Indication – Route and Dose ?Look Up Adverse Effects Elimination –and effects of disease Drug Interactions Patient Information

15. Core Curriculum – Drugs (2) Core Drugs in Hypertension * Calcium Channel Blockers ( eg Amlodipine ) * ACE Inhibitors ( eg lisinopril ) * Diuretcis ( eg Bendrofluazide ) * Selective Beta Blockers ( eg Atenolol) * + AT1 receptor antagonists ( eg Losartan ) * + Centrally Acting Drugs ( eg Clonidine ) * + Alpha Blockers ( eg Prazosin ) + Indicates the need for student awareness

16. Core Curriculum – Drugs ( 3 ) Respiratory Drugs *Inhaled Glucocorticoids ( eg Beclomethasone) * Beta 2 Agonists ( eg salbutamol, Salmeterol) * Ipratropium * Theophylline * [Codeine ] * + Cromoglycate * + Leukotriene Antagonists ( eg Montelukast) * + Acetylcysteine [ ] indicates the drug is found elsewhere in formulary

17. Core Curriculum – Diseases Code M - Diseases that students must know how to manage ( n= 67 ) Code D - Diseases that students must know how to diagnose ( n = 158 ) Code A - Diseases that students should be aware of ( for specialist care ) (n=36 )

18. Core Curriculum –Diseases (2) Typical Code M Diseases * Acute Myocardial Infarction * Deep Vein Thrombosis * Diabetes Mellitus * Constipation * Urinary Tract Infection * Angina * Gout

19. Core Curriculum – Diseases (3) Typical Code D Diseases * Bacterial Endocarditis * Jaundice * Nephrotic Syndrome * Parkinson’s Disease * Bronchial Carcinoma * Limb Fractures * Ectopic Pregnancy

20. Core Curriculum – Diseases (4) Typical Code A Diseases * Addison’s Disease * Cirrhosis of the Liver * Bladder cancer * Schistosomiasis * HIV/AIDS * Cystic Fibrosis * Motor Neurone Disease

21. Core Curriculum - Diseases The Disease system has worked well in those European Countries where it has been piloted. However world wide the criteria for codes M,D and A may well need to change

22. How Should they be assessed? Should examinations be Nationally, Regionally or Medical School based? In Europe most are school based Should there be a specific examination in clinical pharmacology or rational prescribing? With the advent of integrated curricula specific CPT exams have largely gone. Good thing or Bad Thing?

23. Core Curriculum in CPT Assessments Assessments drive the curriculum Students will usually learn only those areas that they think will be exam tested A variety of assessment methods may be needed depending on circumstances

24. Assessements (1) Knowledge based Multiple ( True/False) choice exams ( MCQs) are often unreliable and measure only factual knowledge. Problem solving MCQs give a better assessment * OSCE’s ( Objective Structured Clinical Exams) can be useful but station size is usually limited

25. Assessments (2) Essay writing is usually a waste of time for students and examiners May be better if model answers are agreed Short essays ( eg 10 lines) are possibly the best written test if model answer is used and scripts are double marked

26. Assessments (3) Ideally there should be an assessment of the ability to prescribe safely and rationally This can be achieved in an OSCE (OSPE) but it is difficult to have more than a few stations. * Should some stations carry an automatic failure? ie if you fail the station you fail the exam.

28. Conclusions Much work remains to be done to assess the European situation and to try to produce effective education so that doctors are able to prescribe rationally and safely