Impact of problem-based pharmacotherapy course on the competence of rational prescribing of Sudanese undergraduate medical students

Background: Prescription writing is a skill that almost every doctor will use several times a day. But are medical students effectively taught how to write a complete and accurate prescription? Most commonly the answer is no. There is increasing need for the rational of medicines and the clearly appropriate prescribing is a key to achieve this. Objectives: To find out whether a short training course of problem teaching, improves the competence of rational prescribing among medical students. Methods: All 6 year medical students (Batch 13), Omdurman Islamic university were randomly separated into intervention and control group. Students of intervention group were taught to choose P how to apply this choice to specific patient problem, using the WHO Results: The competence of intervention group is significantly better than the control group p =0.011. The mean results of post test for intervention group was [3.4 ± 4.5] and fo Conclusion: Teaching medical students all basic knowledge about drugs does not guarantee rational prescribing. Additional short course of problem-based pharmacotherapy could be effective in improving prescribing skills Sudanese medical students. Background Prescribing of drugs in current practice is often inappropriate and irrational. There is a great need to ensure that drugs are prescribed and used rationally. Irrational drug prescribing includes practices such as polypharmacy, wrong medication for the diagnosis, use of expensive drugs when less expensive alternatives are available, use of wrong dose (both over and under-dose), and prescribing when medications are not necessary. The rationality of the scripts prescribed by physician is of critical i since bad prescribing habits lead to ineffective and unsafe treatment, causing exacerbation or prolongation of disease and distress or harm to the patient, which add extra burden to the health budgets. Many factors affect a doctor's pres behaviour, such as education, marketing, relationships to the pharmaceutical companies, colleagues, regulatory actions, demands from society and patients and personal characteristics of the doctor. It seems that already bad prescribing behaviour is difficult to cure. Probably, a more effective way to prevent the irrational prescribing is through proper undergraduate training . Most medical schools and health institutes are still using traditional methods for teaching pharmacology i.e. transferring knowledge on drugs through lectures. Further more during clinical training the emphasis is much more on diagnosis than therapeutics, and little time is left 1. Lecturer. Department of biochemistry and pharmacology. Faculty of Medicine Omdurman Islamic University Email: isra-su@hotmail.com 2. Assist. Prof. of Internal Medicine. Faculty of Medicine. OIU & Tropical Diseases Teaching Hospital. Omdurman.


Background
Prescribing of drugs in current practice is often inappropriate and irrational.There is a great need to ensure that drugs are prescribed and used rationally 1 .Irrational drug prescribing includes practices such as polypharmacy, wrong medication for the diagnosis, use of expensive drugs when less expensive alternatives are available, use of wrong dose (both over and under-dose), and prescribing when medications are not necessary 2 .The rationality of the scripts prescribed by physician is of critical i since bad prescribing habits lead to ineffective and unsafe treatment, causing exacerbation or prolongation of disease and distress or harm to the patient, which add extra burden to the health budgets 3 .
Many factors affect a doctor's pres behaviour, such as education, marketing, relationships to the pharmaceutical companies, colleagues, regulatory actions, demands from society and patients and personal characteristics of the doctor 4 .It seems that already bad prescribing behaviour is difficult to cure.Probably, a more effective way to prevent the irrational prescribing is through proper undergraduate training 5,6 .
Most medical schools and health institutes are still using traditional methods for teaching pharmacology i.e. transferring knowledge on drugs through lectures.Further more during clinical training the emphasis is much more on diagnosis than therapeutics, and little time is left skill that almost every doctor will use several times ively taught how to write a complete and accurate er is no.There is increasing need for the rational use e prescribing is a key to achieve this.t training course of problem-based pharmacotherapy ational prescribing among medical students.ents (Batch 13), Omdurman Islamic university were randomly separated into ts of intervention group were taught to choose P-drug for different diseases and ient problem, using the WHO-six steps problem solving approach on group is significantly better than the control group p =0.011.The mean results 3.4 ± 4.5] and for the control group was [2.1 ± 1.9].nts all basic knowledge about drugs does not guarantee rational prescribing.sed pharmacotherapy could be effective in improving prescribing skills for pharmacotherapy, therefore there is no structural training regarding how to use the knowledge about drugs when actually treating patients, and medical students are not always trained adequately in rational therapy Medical students, as tomorrow's doctors, need training in clinical pharmaco particularly focused on rational pharmacotherapy as well as basic pharmacological knowledge in order to make pharmacotherapy decisions.Clinical pharmacology is a 'bridging field' of medicine that aims to promote rational use of drugs 8 which is defined as a drug treatment that is expected to be effective, safe, convenient and low cost 9 .
Undergraduate education focused on rational pharmacotherapy was one of the solutions offered to repair the deficiencies of classical teaching of clinical pha based pharmacotherapy is a training course developed by World Health Organization (WHO) using a normative model known as Student Guide to Good Prescribing .This model of problem based pharmacotherapy teaching was introduced and tested in several faculties in both developed and developing countries, which have shown significant improvement in the ability of senior medical students to choose the drug rationally.
The objective of this study was to assess the effectiveness of a short training course of problem-based pharmacotherapy teaching in improving the competence in rational prescribing skills among undergraduate medical students in Sudan.

Methods
The impact of teaching problem pharmacotherapy was measured by means of f rational prescribing e randomly separated into g for different diseases and ng approach.p =0.011.The mean results antee rational prescribing.g prescribing skills among therefore there is no rding how to use the when actually treating tudents are not always onal therapy 7  ) of faculty of medicine-Omdurman Islamic University-was randomly assigned into two groups, intervention group (n=93) and control group (n=125), simply on basis of their internal medicine rotation assignment for one group rotation of males and females students This is part of routine scheduling of their clerkship.This assignment therefore was not biased because we did not determine the students in each group.Both groups had already studied classical teaching of pharmacology during preclinical years.The intervention group was invited to participate in two days (4 hours) course problem-based pharmacotherapy delivered in small subgroups of 10 students.They were provided with WHO's Guide to Good Prescribing sheet as one of the key references in this course, British National Formulary and materials related was provided.At the end of each session the study group was provided with a questionnaire to address student' satisfaction with the course.
During the training course, students of the study group were first introduced to the WHO concept of The Guide to Good Prescribing.Briefly students learned to develop a standard pharmacotherapeutic -approach-to selected indications resulting in a set of self selection for the best drug of choice selected by a person called P (Personal)-drug according to the criteria of efficacy, safety, suitability and cost.They were taught to solve different patient problems in different clinical topics and to apply these drugs to specific patient problems using step by step approach, the approach include six basic steps 3 : 1/ define the patient's problem.2/ specify the therapeutic objective.3/ choose the treatment for that specific patient.4/ write a prescription.5/ give information and advice to the patient.6/ monitor and/or stop the treatment.Mixing and exchange of the information was not expected between the control and intervention group because each group studying in a different rotation assignments.
After finishing the course to the assigned intervention group, a competence in rational prescribing was assessed through a final test for both groups, consisting of three problem-based cases.Baseline testing would identify potential variance between students' abilities.However baseline testing was not performed as it may alert students to the study and the possibility of further tests and hence potentially bias the study results.

Statistical analysis
The result of both groups was computed to the points achieved in each group.For comparison of mean, student's t-test was used to determine whether there is a true difference in the test results between two groups.

Results
Of the 93 students allocated in the intervention group 43 (46%) were males and.Only one female (2%) and two males (5%) did not attend the session.

Test Results:
The mean (±SD) score of the objective post test was [3.4 ± 4.5] for the intervention group which is significantly better than that of the control group [2.1 ± 1.9] (P = 0.011).
Figure (1) shows the student scores of the intervention group and control group.As a reply to the direct questions 90% of students affirmed their need for more time, sessions and problems from the course, and suggested that this course should be taught earlier than the final year.

Discussion
The results showed that a short training course of problem-based pharmacotherapy, based on WHO Guide to good prescribing significantly improved the ability of students to solve patient problems.[13][14][15][16][17] Overall responses to the questionnaire were positive.The majority of the students rated the course to be helpful and useful in prescription writing, but for the best outcome more time should be considered.The problem-based environment was also well perceived and considered as interactive and encouraging method of learning .

Conclusions
The preclinical traditional lectures of pharmacology taught the student what to choose for different diseases studied but the problem at clinical and final years is how to choose and we think additional course of problem based pharmacotherapy could solve this problem, and will be an effective approach for rational prescribing.

Sudan rmacotherapy course on the competence of rational prescribing danese undergraduate medical students
h Eldin I Kheder 1 and Abdelsalam M Nail 2 1. Lecturer.Department of biochemistry and pharmacology.Faculty of Medicine Omdurman Islamic University Email: isra-su@hotmail.com 2. Assist.Prof. of Internal Medicine.Faculty of Medicine.OIU & Tropical Diseases Teaching Hospital.Omdurman.