The pen is mightier than the sword. Reinstating patient care as the object of prescribing education

Abstract

Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

The wolf shall dwell with the lamb: The power dynamics of interprofessional education

“…We have argued elsewhere that optimising prescribing via the vertical axis is less likely to succeed. 7 To conclude, socioculturally informed interventions, as Stalmeijer and Varpio illustrate, can energise interprofessional education. We should harness, but not romanticise, landscapes of practice because professional power, without which patients cannot benefit, 10 messes up landscapes.…”

“…6 We have enacted a different form of horizontal accountability to nurture interprofessional practice in Northern Ireland. 7 Guided by AT, we followed the lead of others before us 8,9 and conducted a formative intervention addressing a potent threat to patient safety: new medical graduates' unpreparedness to participate in the interprofessional task of prescribing medication safely. Minimal change to rules (local codes of practice) and the simple expedient of giving medical students tools (pens filled with purple ink) gave students an active place within the practising community of doctors, nurses and pharmacists.…”

“…Here, and, increasingly, in other European countries, whole hospital wards are run by interprofessional groups of students under interprofessional supervision 6 . We have enacted a different form of horizontal accountability to nurture interprofessional practice in Northern Ireland 7 . Guided by AT, we followed the lead of others before us 8,9 and conducted a formative intervention addressing a potent threat to patient safety: new medical graduates’ unpreparedness to participate in the interprofessional task of prescribing medication safely.…”

“…The potential for benefit to patients and clinicians energised the process, fast, and at low cost. We have argued elsewhere that optimising prescribing via the vertical axis is less likely to succeed 7 …”

Destabilising institutions to make healthcare more equitable: Clinicians, educators, and researchers co-producing change

“…(Grilo Diniz et al 2020) Acknowledging the stultifying effect of standardizing human behaviour for Objective Structured Clinical Examinations (OSCEs) opened up possibilities to release latent energy for change in medical education. (Reid et al 2020) Subtle changes in the subject of educational activity can also catalyse change; for example, a simple intervention changed medical students from observers, becoming competent for practice, into residents-inwaiting, becoming capable by participating in practice (Gillespie et al 2020). A humble mediating tool -a pen filled with purple ink -mediated students' identity change.…”