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Prescribing:What are the competencies?
Charles Mitchell, Ian Coombes, Elaine Lum
CSEPUniversity of Queensland
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Competence
• is the ability to perform a specific task, action or function successfully
• more than enabling knowledge
• rather the appropriate application of knowledge
• includes how needed knowledge effectively obtained
• ideally, should include how competencies are acquired and how assessed
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Proposal
Prescribing should be considered in a similar way to procedures where a combination of knowledge and, more importantly, competencies (skills) are prerequisites to be demonstrated before being allowed to perform a specific complex task.
The main difference is that procedures require psychomotor skills in addition to cognitive skills
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4 Domains of Prescribing
Enabling Know-ledge
Info Gathering
Clinical Decision Making
Communicate Decision – Prescribe
Monitor & Review
Experience
Feedback
Self -Reflection
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• Take/ review medical & medication hx; physical examination; Investigations
• Compare medical & medication hx
• Assess adherence to meds; risk factors for non-adherence
• View/ assess patient’s needs holistically (psychosocial, physical)
Info Gathering
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Info Gathering
•Access and interpret all relevant records for past management•Review nature, severity and significance of the symptoms/problem/diagnosis•Consider natural history of the clinical problem/diagnosis•Request and interpret relevant diagnostic tests
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• Diagnosis • Consider drug & non-drug options• Balance benefits and risks of specific drug(s) • Consider drug-drug, drug-comorbidity interactions• Consider cost/availability of options• Select drug, form, route, dose, frequency, duration
Clinical Decision Making
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• Other medical staff/ prescribers • Pharmacy staff to review; dispense; arrange supply• Nursing staff to administer or supply• Patients/carers to administer • Contingency plans
Communicate Decision – Prescribe
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Review:• Control of symptoms
and signs• Adherence• patient’s outcomes
•Consider need to tailor therapy to patient, continued or ceased •Any need to consult
Monitor & Review
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Rational prescribing – WHO Model
1. Define patient’s problem
2. Specify therapeutic objective(s)
3. Choose your standard drug and verify its suitability
4. Start treatment
5. Give information, instructions & warnings
6. Monitor (and stop) treatment
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Mapping the 4 Domains of Prescribing
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Domain• Information gathering
Compe-tency
• Assess adherence to current & past medications and risk factors for non-adherence
Learning Objec-tives
• Understands the importance of assessing adherence• Knows the risk factors for non-adherence• Know the evidence for strategies to improve adherence• Acquires skills for detecting non-adherent behaviour• Acquires skills for encouraging medication adherence
Assess-ment
• MCQ• OSCEs• MiniCEX (Clinical Examination)
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Processes for medical staff
• SMPT
• NPS modules (UG & PG)
• OSCEs
• Pre-employment assessment
• PGY1/2 program
• WBA
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SMPT 2011
• Based on errors made by interns in recent years
• Focuses on PINCHA drugs
• Basic clinical pharmacology – now presented in VOPPs
• Eight F2F sessions on competencies delivered in Y4 Medical Rotation
• Proposal to split and introduce earlier
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SMPT 2011
• Based on errors made by interns in recent years
• Focuses on PINCHA drugs
• Basic clinical pharmacology – now presented in VOPPs
• Eight F2F sessions on competencies delivered in Y4 Medical Rotation
• Proposal to split and introduce earlier
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High Risk Medications
ntibiotics: aminoglycosides and previous allergies to penicillins and sulphonamides
eparin, enoxaparin and warfarin
ytotoxics and immune suppressants
arcotics and NSAIDs
nsulin and oral hypoglycaemics
otassium and other concentrated electrolytes
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SMPT 2011
• Based on errors made by interns in recent years
• Focuses on PINCHA drugs• Basic clinical pharmacology – now
presented in VOPPs• Eight F2F sessions on competencies
delivered in Y4 Medical Rotation• Proposal to split and introduce earlier• Assessment under development
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OSCEIn a general practice, you are about to see a 21 year manwho has long-standing asthma. Seen occasionally in thepractice but you have not seen him previously. He hasjust seen the practice nurse who recorded the following:Recently waking several nights a week with SoB andwheeze. Also SoB on mod exertion. No evidence ofrecent infection. Rx Symbicort 400mcg/12mcg) two bdand Ventolin 2 puffs prn. MAT Turbuhaler and pMDI OK
On examination: Non-productive cough. Not cyanosed.Chest exam - moderate insp and exp wheezes.Spirometry reveals moderate obstruction with an FEV1 of2.7 litres and FVC of 4.5 litres(FEV1/FVC 60%)
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OSCE
YOUR TASKS ARE TO:
• Take a focused history from this patient. You should take no more than 5 minutes on this task
• Ask the examiner for any other findings you would seek on physical examination.
• Discuss your plan of management with the patient
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OSCE
WHAT WOULD YOU DO?
Aspects of history
Request for physical finding
Advice
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Discussion Questions
• Is the prescribing cycle a reasonable framework to formulate the required competencies for prescribing?
• Are there any other detailed frameworks currently in use?
• What are you doing in this space? Care to share?
• Should there be a national view?• If yes, how do we proceed?