New Assessment Evaluates Prescribing Among UK Medical Students

A national standardized assessment on prescribing adequately measures the knowledge and skills of graduating medical students in the United Kingdom, according to a study published online May 21 in the British Journal of Clinical Pharmacology.

"The [Prescribing Safety Assessment (PSA)] has proved to be a powerful tool to emphasise the importance of prescribing and the principles of clinical pharmacology," write Simon Maxwell, MD, PhD, from the University of Edinburgh Medical Education Centre in Scotland, and colleagues. It also strengthened students' familiarity with the online standard reference resource for UK prescribers, they add.

"The key points from this report of PSA2016 are that: (i) the overall performance of the candidates was good, (ii) there is some evidence that performance is improving, (iii) the reliability of the assessment is improving, and (iv) there is significant variation in the performance of students from different medical schools," the authors conclude.

Past studies cited by the authors have found that physicians in their first year of clinical practice make errors in their prescribing at a rate of 7% to 10%. Even among experienced physicians in the hospital and general practice, the prescribing error rate is about 5%.


Therefore, the British Pharmacological Society and Medical Schools Council Assessment developed the PAS in 2010 to evaluate final-year medical students' knowledge, judgment, and skills related to pharmacology and writing prescriptions.

The 2-hour online assessment aims to assess "complex skills including powers of deduction and problem solving that are relevant to the work" of physicians in their first and second years in the National Health Service. Before the exam, students have access to a dozen information videos about the assessment, and four practice tests of 30 questions each, with feedback for each question.

After a pilot run in 2012 and 2013, the assessment became fully implemented in all the United Kingdom's medical schools in 2014. In 2016, the assessment became required for all physicians entering their first year of postgraduate training. Those who did not pass could still practice clinically under extra supervision, but had to pass before the end of that first year.

In 2016, an overall 7343 final-year medical students from all 31 medical schools in the United Kingdom took the PSA, and 95% passed. Pass rates were 91% in 2015 and 94% in 2014. Of those who did not pass the 2016 assessment, 261 students retook it, and 80% of them passed. Of all graduating UK medical students in 2016, less than 1% failed by the time they completed their last year.

The strongest skill area was on adverse drug reactions, where the median score on each of the four versions was 88%. On the data interpretation questions, however, the median was 67%. "A potential reason for the relatively poor performance on the latter section (which was also noted in PSA2015) is that data interpretation items are presented as the last section of the assessment and some candidates may be running out of time when these items are attempted," the authors noted.

The test's four different versions were found to be internally consistent, with average raw scores ranging from 76.1% on one version to 80.0% on another. However, scores varied significantly between different schools' cohorts (P < .001), with averages ranging from 63.2% to 78.2%. The overall performance of cohorts from each individual school in 2016 strongly correlated with that school's scores the previous year (P < .01). At all except two of the schools, average scores improved from 2015 to 2016.

"Prescribing is a challenging task for any healthcare professional," the authors write. "Prescribers have to select the correct medicine, dosage, route, and frequency of administration, sometimes in the face of diagnostic uncertainty, taking into account potential individual variability in pharmacokinetics and response as a consequence of comorbidity, genetics, and interacting drugs." Then the prescriber must counsel and appropriately monitor the patient while they are receiving the therapy to record benefits and harms.

The assessment contains eight sections focused on each of the following areas: prescribing, prescription review, planning management, providing information about medicines, calculation skills, adverse drug reactions, drug monitoring, and data interpretation. The assessment's questions relate to 60 patient scenarios in seven clinical areas: general internal medicine, general surgery, elderly care, pediatrics, psychiatry, obstetrics and gynecology, and general practice. Further, at least two questions in each assessment focus on opioid pain relievers, anticoagulants, insulin, antibiotics, and intravenous infusion fluids.

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