I'm Dr Halady, John Halady, from King's College London at the Medical Schools at Guy's,
St Thomas'ys in King's College London, and I've been involved with this organisation
for something like eight years now, and I must say that Millie provides a bigger stimulus
to some of my intellectual approach to my subject, which is pharmacology and toxicology,
than many of my learned colleagues, because Millie keeps prodding me in ways that my learned colleagues
don't, and says, why isn't this happening? What do you know about this? And these sorts of questions
from somebody who's not originally scientifically trained are very difficult to deal with, and I'm sure
that any of you here who've had anything to do with Millie will be aware of just how acute she is
and how hard working, and the need for formal science training doesn't really come into the whole equation.
She's a very perceptive and hard working lady, and she's really got a great deal of interest going in this area.
Now, I was unfortunately not here this morning, I was teaching first year medical students something about
pharmacology and their first approach to the subject, and I'm involved primarily in the first two years
of that course, but also on the pharmacology and therapeutics course right throughout the five years
of the medical training, and I have to say I'm very pleased that today we've got Simon Maxwell,
who's another Edinburgh lad myself, and he unfortunately went to Birmingham to do his training,
but he's found his way back to Edinburgh now, and he's going to tell us something about prescribing,
and prescribing is an area which, along with pharmacology and adverse drug reactions,
slip very much down the medical education priority list when the new integrated curricula came along,
and medical schools throughout the country, except those that held strong to some pharmacology teaching,
are trying to bring back up the level of teaching on pharmacology and adverse drug reactions
because what happened, the products of the new integrated courses and programmes in medical schools
were getting to the stage where they were in their apprenticeship having qualified MBBS,
and finding that they didn't know enough to treat patients with confidence with drugs,
and it's in this situation, I think, that education has to be very careful that in looking at integrated programmes
and new styles of teaching, the requirements, the fundamental requirements of prescribers are looped after
because prescribers have an enormous responsibility, not just to know about the drugs,
but to look after their patients, as Professor Healy said, to care for their patients,
and to look into things when they go wrong, just as much as when they go well.
I'm also intrigued to hear what Simon is going to say, if indeed he does say anything,
about his involvement with NICE, the National Institute for Clinical Excellence.
Now, in my opinion, NICE is a very important group because it tries to look dispassionately
at what the NHS can best afford.
There is a limitation on resource for drugs and other treatments, and NICE is trying to make judgments,
sometimes very invidious judgments, and they've got the government and regulators on one side,
they've got the doctors on the other, they've got the patients on the other,
and right at their back, with a knife at the ready, are the drug companies.
And NICE is a very important organisation because it is doing its best,
and it gets very bad press, I feel, doing a very good job so far.
So, Simon, thank you.
John, thank you very much for that. Thank you to Mili and April for inviting me to come on today.
I have to say, I feel rather humbled, really, to be delivering the last talk of the day,
having heard such powerful testimony earlier on about the impact of drugs on people's lives
and the wonderful oratory from Professor Healy.
But I do feel that education is clearly a very important aspect of this whole story,
and I'm glad we're going to devote a little bit of time to it.
I'm actually not going to talk about NICE very much, because I suspect,
well, I've got to train at six o'clock, and I don't know when anybody else is going home,
but that really would be another story altogether.
I'd also like to say, really at the outset, I'm a consultant physician,
so I do quite a lot of prescribing of drugs, working the National Health Service,
and I'm also an educator in one of the leading universities in the UK.
I'd like to say to the audience that, although you may feel that the medical profession
has had a bit of a bad press over the last four or five hours,
I'm really privileged to work with young 18 to 22-year-old students of the highest calibre,
and I can say to you hand on heart that I think the future of the medical profession
is at least in as good, if not rather better hands than maybe it was a few years ago.
I'm going to rush through really quite a few slides and try and cover
what I think the current prescribing challenges are.
Is there an education shortfall?
I guess one of the key questions that needs to be answered.
Does education matter?
You might think it, obviously it does, but does it actually matter what we do
with these extremely articulate, intelligent kids at university level?
Do we know what the acceptable standard is?
I mean, what do you expect your doctor to know when they're treating you?
How are we going to achieve that standard if we know what it is
and what developments are in the offing at the moment?
This may shock you slightly, but it's just a stylised pictogram
of the prescribing activity of a typical British doctor,
starting at undergraduate medical school era,
where they go very rarely towards a piece of paper on which they can write a prescription.
They walk out of medical school and then they have to write about 30 or 40 prescriptions every single day,
and then as they get a little bit more mature and older,
they're able to hand that responsibility on to the doctors who are younger than them,
and the prescribing activity drops off very quickly.
And it's really for that reason, although education is important throughout that lifespan,
I'm particularly interested and focus a lot of my activities on what goes on in the undergraduate period,
because I feel that it's the knowledge, attitudes and skills which we inculcate at that stage,
which generate prescribers who are going to be caring for their patients
and are going to be interested in the kind of follow-up to drug exposure
that we've heard about going so badly wrong earlier on this afternoon.
So, what are the current prescribing challenges that I'm trying to prepare my students for?
Well, there are more drugs than ever before.
It seems that drugs go into the formary at much faster rate than they actually leave it.
So, in fact, the British National Formary is a considerably bigger book than it was when I graduated 20 years ago.
There are more patients around for a given day in any hospital up and down the country,
any hospital ward, accident and emergency department.
There are far more patients coming through each day than there were before.
Those patients are also, on average, older and more vulnerable,
particularly by the way to neuro and psychiatric adverse effects.
There's more polypharmacy which we touched upon and that follows obviously from a society
where every member is taking on average more drugs than in the past.
The regimens of drug use are more complicated.
There's a lot more evidence-based guidelines out there.
There's greater demand from patients.
You, as consumers of the National Health Service, expect more and more of your doctors.
You ask them what are the adverse effects of this drug.
What should I be worried about? You expect them to be able to answer that question.
So perhaps given what I've just said, it's not surprising that if you look into the literature
and start examining studies that have looked at major hospitals around the UK
and other parts of the world, it's not that difficult to find studies
showing considerable numbers of medication errors.
This was just one London teaching hospital, an example from four or five years ago,
showing that on about five or six general medical wards, there are 135 drug errors each week,
a quarter of which were serious, and the majority of those errors were made by young doctors.
The kind of people that I was just showing you just stepped out of medical school.
Not necessarily, by the way, because they're any worse at prescribing
than those who are more mature, but as I try to illustrate to you,
they in a hospital setting do most of the prescribing.
Of course, if you look nationally, the National Patient Safety Agency collects data
on medication incidents, not all of which are obvious errors,
but they're incidents relating to medicines 50,000 reported each year.
So that's a fairly stunning figure and suggests that this is an important public health issue.
Wondring round an individual hospital ward, here's an audit in one of the hospitals I worked in recently,
and you can see that, on average, every single chart at the end of a patient's bed
had four prescription writing errors, I hadn't been signed off, wrongly dated, et cetera,
and one prescribing error, the drug was either there when it shouldn't have been
or an obvious drug had been admitted that should be there.
You may have seen already this slide from my colleague, Professor Per Muhammad, in Liverpool,
just illustrating that, actually, when it comes to dealing with patients coming to hospital,
a very significant proportion of them are there because of adverse effects related to the medicines that they're taking.
But if you look at the red text, I think that says it all.
I hope all recognise that you can't eliminate adverse reactions, all drugs have them and always will do,
but this study implied that about two-thirds of those adverse reactions with a bit of forethought might have been avoided.
Just to make the situation even more worrying, this was the trend of reported deaths from adverse drug reactions
in England and Wales during the 1990s, deaths from medication error lower down.
That's an important trend and well worth taking account of.
This is similar data from the United States, where deaths related to medication, not necessarily errors,
adverse effects and errors account for, I think, the fifth commonest cause of death in that country.
That, I think, is very dramatic evidence, but actually that's the tip of the iceberg.
There's plenty of evidence that we've also heard about today of overprescribing of drugs
which really shouldn't have been prescribed for pretty shaky indications
and also underprescribing of drugs which we know are likely to improve the outlook for patients.
Having said that, and I could have talked for a lot longer about all of those kinds of issues,
you might feel that one thing that medical schools and postgraduate institutes really would be focusing on
and would stand out like a pillar if you care to examine their curriculum
would be pharmacology, therapeutics and prescribing.
Actually, there's been quite a lot of debate about this.
This is just one news story from the BBC website a couple of years ago, highlighting some comments
from some of my colleagues about whether, in fact, medical students were getting enough education in this area
to allow them to do their everyday job when they qualified.
Let's ask the question, are medical students adequately prepared to prescribe
when they walk out of medical schools in the UK?
As I hope I'm good at illustrating, that is a very difficult question to answer.
Actually, out there, there's really much more anecdote and opinion than there really is any hard evidence.
One thing which I think would absolutely deal with that question is if every single medical school in the United Kingdom
had a clear prescribing assessment that focused on prescribing and basically signed somebody off.
If you couldn't pass that exam, you'd get to walk on to a hospital ward and start prescribing
and then go on from there maybe to general practice.
But actually, hardly any medical schools in the United Kingdom have that kind of assessment
built in to their final examination structure.
So, in order to try and deal with the question that I've posed there,
we really just have to look largely at the opinion and some very small-scale studies.
Anecdote, surveys, regulatory visits, et cetera.
I'm a clinical pharmacologist. That's my academic background.
That's why I'm interested in drugs and drug therapy and it's perhaps not surprising.
Most specialty groups feel they're not getting a big enough piece of the cake
and maybe their area is not being tackled as carefully as it might be.
So, maybe you can take all of that just with a pinch of salt.
People like me moaning on that our area hasn't really got the attention it deserves.
However, I think the views of medical students are really quite important
because one brave medical student who wrote in the British Medical Journal about six years ago now,
she'd been sent off to a conference about nurse prescribing.
Nurses had been given the opportunity to start prescribing independently
and so were being educated specifically for that.
And I think without going over all the small texts, the take-home messages she said,
basically she couldn't believe that these nursing students were getting 35 days
of dedicated practice in this area when she seemed to be just sort of picking up the odd
bit of information as she went through.
And she says down there at the bottom,
will prescribing be just another aspect of the job I'm expected to pick up
as I begin my career as a doctor.
Now, there are a lot of small-scale surveys in individual universities
and on the back of that, I and colleagues in Edinburgh tried to do an online survey
of medical student views.
So, this doesn't say whether medical students have been properly prepared,
it doesn't say whether they're good or bad prescribers,
but it's their views on their journey through medical school
and how it relates to education for prescribing.
So, there are about 2,500 responses,
around about an average of 100 responses per medical school.
And we asked an awful lot of questions, but here are just a few of them.
We've asked them to respond to the question,
I feel that the amount of teaching in pharmacology,
therapeutics and prescribing during my course is or was,
and then we offered them the options far too much,
two people responded to that, about right, 20%,
and the rest felt that possibly they weren't getting as many,
and maybe they would answer that way to all areas.
But in fact, we've subsequently got data to show that they're perfectly prepared
to say they've had their fill of certain things.
So, I think that genuinely is a signal there.
How do they learn about clinical pharmacology,
which for those unfamiliar with it, essentially is the academic science
underpinning prescribing and use of medicines.
And again, for those who can't quite read the text,
a distinct course in clinical pharmacology and therapeutics,
round about 17% integrated as part of a sort of bigger picture,
mainly opportunistic learning.
I basically just picking it up as you go along, round about 40%.
So, I'm not saying any of that is right or wrong,
but that's a big change, I think,
for where we might have been 25 years ago
when there were clinical pharmacology courses in most medical schools.
Here's another interesting one.
Again, just from the cohort who answered,
who were only a fifth of all the students that we might have got to,
do you feel that your assessment thoroughly tested you in this area?
And you can see that the majority either tend to disagree or disagree,
kind of backing up the comments I was making earlier
that actually not too many medical schools have an absolute
pass-fail assessment around prescribing
that students have got to get through,
otherwise they have to retake.
Here are the skills that medical students felt confident in
and prescription writing.
You can see under half really felt they were confident,
whereas they felt they were able to talk to patients
and take a drug history.
Although I haven't got time to show you the slides,
there was great variability.
Some medical schools got, metaphorically speaking,
fan tick from their students.
Others weren't so happy with their education.
I think one thing which has changed this a bit,
this whole story now, is that the NHS has got interested,
not surprisingly, because although the universities train
medical students to become young doctors,
actually where they practice and the organisations
take carry the can if things go wrong,
are national health service hospitals.
I think it speaks volumes that many of those now
have their own prescribing assessment that they give
to their new doctors as they walk through the door.
I think that's desperately sad, but it does say to me
there's a lack of confidence there on behalf of some NHS trusts.
Again, this is anecdote, but there was an interesting story
from the north of England not too long ago
where the medical director effectively was so unhappy
with what he saw in those assessments
that for a period of two or three months
he withdrew prescribing rights from his new cohort of doctors
until they did a bit of retraining
and went through the assessment again.
Now, I have to say that because I'm an educator in this area
and particularly interested in improving things,
I have a conflict of interest in what I've presented to you
and I think it's only fair to say that there are others
who disagree some very strongly with the notion
that there is any serious concern in this area.
I think in particular the Medical Schools Council
and the General Medical Council point to the fact,
two correct facts is that Medical Schools are very regularly reviewed
for their curriculum content and what's going on,
and secondly that nobody has proven that curriculum A
leads to more disasters in the National Health Service
ultimately than curriculum B.
So where am I coming from in implying
that maybe we should improve
the amount of pharmacology and therapeutics in the curriculum
and it's very difficult really to overcome that argument very strongly
but all I can say to you is that it's not just clinical pharmacology
and some people, some of the academics like myself
who have concerns, there are documents now appearing
from a whole host of different organisations
saying more or less education in prescribing
needs to be strengthened and this isn't a UK problem.
This was a meeting I was involved in,
hosting in London a couple of years ago
looking at the issue on a European level.
Are changes in medical education
that John has already alluded to,
are they relevant here?
Or what you might be interested to know,
I'm sure you don't spend a lot of your time
cogitating over undergraduate medical student education
but if you do or you start searching around
you'll find that a hugely influential document
in this regard was tomorrow's doctors
produced by the General Medical Council
who oversee undergraduate education in the United Kingdom in 1993.
In many ways that was a good document
it highlighted a real problem which was that medical students
were having their heads absolutely crammed full
of completely useless facts.
They were getting far too much anatomy,
far too much biochemistry that was totally irrelevant
to what they do on a hospital ward
or in a general practice when they graduate.
So this document basically said
let's reduce the factual burden,
let's integrate everything so there are not little fiefdoms
of individual academics teaching their specialty.
Let's make things systems based around the heart,
the lungs, the brain, etc.
All well and good so far in general terms
but they said they avoided all reference to traditional subjects
and disciplines urging into disciplinarity.
Well with regard to this meeting
one of the traditional subjects
that all medical schools had was pharmacology
and allied to clinical pharmacology
and I'm afraid you might say it's just a chance effect
but since that time the numbers of departments of pharmacology
and clinical pharmacology in the UK has taken a nosedive
and I'm not saying that education in this area was rosy
when I went through medical school 20 years ago
but what I do know is that that document
has made it very difficult to respond
to the kind of problems which I've highlighted
in some of my earlier slides
and if you like see a renaissance of education in this area
because it doesn't conform with what is the current ethos
in undergraduate medical education.
The problem with the model is
you tend to lose the visibility of teaching in relationship
to pharmacology and therapies
and drugs as everybody in this audience certainly knows
don't respect system boundaries.
So if you've got a system based curriculum
then you may find specialist in the heart
very happy to talk about all the good things
drugs can do to the heart
but maybe not so keen to remind you to think about
some of the collateral effects.
Is there any evidence that education
in rational prescribing matters?
So I have my way and there's a lot more education
in this area but does it matter anyway?
Well I think those who said there are no studies
to prove this are correct I'm afraid
but when are we going to deliver a study
which follows up an enormous number of students
has them randomised to different curricula
looks at all their prescribing
looks at what will be still a relatively small number
of adverse effects and medication errors
incredibly tricky study to do
and frankly I don't think we'll ever get round to doing
not least because you've got to then coordinate things
between quite a lot of universities
who would then have to start comparing their activity
and that might be a bit of a problem
to actually get that done.
However there are some circumstantial reasons
to think that education matters.
Here's a well documented study in the Lancet
from six years ago where they debriefed young doctors
who had made medication errors
and a significant proportion of them indicated
that they felt that training and preparation
to use the drugs they were using was an issue.
There are also a number of small scale studies
which do show that if you give an intensive course
in relation to safe prescribing you can improve
prescribing practice at least in the short term.
Another area which has really dogged all of this
which I think I alluded to earlier on
is do we know what the acceptable standard is?
What should we expect our young graduates
from medicine to be able to do and know
in relation to drugs?
Well here's what the General Medical Council
tomorrow's doctors update said so from having said
almost nothing about drugs in 1993
they now devote parts of about five paragraphs to it
and I'm not complaining about that
but it's pretty vague isn't it?
It still doesn't really tell an educator
or a medical school exactly where they have got to get
and that has led of course to the confusion
since nobody knows or there isn't a defined standard
how do we know where students have got to be
and whether they are there or not?
It's all a little bit up in the air.
Here's competence for safe practice.
You'd like to think your medical school could get you there
but some people have said maybe not unreasonably
that if medical school can't get you there
as long as you work in a supervised environment
with an accelerated postgraduate teaching programme
you can be got there pretty quickly in a postgraduate phase.
My concern backed up by some data we've been gathering
is that actually a lot of young doctors
are perhaps not as well supervised as they might be
and may be heading off in that trajectory
so what we really need to do is gather better evidence
for all of this but there's a lot of anecdote
and some support to suggest that's what's been happening.
However I'd like to give you a sort of brighter finish
to last few slides of the talk.
Things have been changing.
That was where we were maybe about a year ago
but I think hearts and minds are changing a bit
after some of those concerns hit the press.
The General Medical Council and Medical Schools Council
to their credit convened a group
which included specialists in the education field
representatives from the National Health Service
and created a safe prescribing working group
of which I was part.
A tremendous leap forward was that for the first time
everybody in the room who was represented agreed
on what we expect a British graduate to be able to do.
Those are just the headlines but if you're interested
in going to the web site there's more detail there
so that was a tremendous step forward
in helping us to unravel this whole area.
What's the optimal learning environment?
What should we offer to students?
I was part of a British Pharmacological Society group
who offered a view on this.
The British Pharmacological Society being a learned academic group
who are interested in drug development, drug usage
in the National Health Service.
Really we laid down about six important issues
for undergraduate education,
for medical school education.
The first important thing which we felt maybe was missing
in some areas was leadership.
Somebody who's got the enthusiasm to continually drive home
the message about basic principles of pharmacology,
good prescribing practice, communication, following up,
recognising patients are different, reporting adverse,
all of these basic things.
A sort of millicieve really within an academic setting.
Somebody who's got the enthusiasm
and drive to push things through.
We also felt that there had to be visibility
for pharmacology and therapeutics in the curriculum.
The students don't know it's there
and they don't actually see that there's a specific assessment
dedicated in that area.
Given that they've got hundreds of others,
is it easy to motivate them?
It's a bit of a problem.
They could easily lose sight of what's going to become
their major postgraduate skill.
We felt that learning in this area is so enormously difficult
with thousands of drugs.
All medical schools should have a student formary
which focuses learning around the most commonly used ones.
We felt skills practice needed to be upregulated,
problem-solving and e-learning.
This is just an example of skills practice
which I'm sure all of you will recognise in particular
being able to speak to patients in a coherent way
and explain the kind of important bits of information
that they expect to have explained
in order to make informed decisions,
being able to write a safe prescription,
the yellow card, being able to report an adverse drug reaction,
being able to interpret data,
and, by the way, being able to calculate
which wasn't a universally accomplished skill we discovered.
We're particularly keen on virtual learning environments
and I think the future is not going to be people like myself, John,
David standing up and lecturing to students.
It's actually going to be a lot more interactive online
and, in Edinburgh, we've been developing that sort of approach
for a number of years now.
Actually, largely out of necessity
because we didn't seem to be able to fight our way back
into the curriculum as strongly as we felt we should have done,
so we developed this approach and the students love it, actually.
We have definitely moved into a new era
and students really do take to learning this way.
This is just an online formary
which allows them to get information about drugs,
including, you'll see there, adverse drug reactions.
Because of time,
I'm really only going to make a couple of other comments.
I've dwelt on undergraduate education,
but, of course, there's a whole lifetime of development
in the areas of clinical pharmacology and therapeutics
and that has to be reflected in the kind of education
we offer to postgraduate doctors
and, indeed, the new prescribing groups, nurses, pharmacists, et cetera,
who are coming along.
Where do we go from here, Chairman?
Well, tomorrow's doctors is about to be updated again
and I am hopeful that, in fact, the General Medical Council,
who we've been collaborating with now for a little while,
will, in fact, incorporate a much stronger statement
on the importance of reaching certain goals
in relationship to pharmacology and therapeutics.
We have secured some funding
from the Department of Health's e-learning initiative
to support the development of a website
which will be made freely available
to all undergraduate students within the United Kingdom
and, indeed, NHS organisations, which will be a repository
for problem-based learning and other information
in relation to education about safe prescribing.
There are a whole lot of other things
I could have gone on to talk about the style of a prescribing.
Do we need a national prescribing assessment?
How can we smooth off this immediate prescribing barrage
that young doctors are given the day they walk out of medical school?
Do we need to change our prescribing forms?
What impact is electronic prescribing going to have?
I hope that's going to be very positive
in terms of medication errors and adverse events,
but some of the early data suggests
that you can make new kinds of errors
and have new kinds of problems in an electronic world.
Perhaps the very last thought I will leave with you
and I think it's a very important one for this audience
and what April has been trying to do.
That is patient empowerment.
As the knowledge horizon disappears into the distance,
you're not going to be able to have your doctor
know everything that you want them to know.
We hope they might be better than the general public
at actually searching for the information,
but they're certainly not going to know everything.
I think there's a tremendous mileage in the future
in increasing patient empowerment
through the provision of information in readily digestible forms
such that patients themselves can get involved in the discussions,
can prompt their doctor and get truly involved
in a concordant decision about the prescriptions which affect them.
Thank you very much.
Thank you very much indeed, Simon.
That was a very fine, interesting talk
and very relevant to the rest of the proceedings today, I think.
I don't know if we have the open panel discussion
and I'm wondering whether we should have any...
Does anybody have any points that they'd like to make specifically
about Simon's talk at this stage?
And then we'll take three or four questions on Simon's talk
and then go on to the open panel discussion.
He can answer questions there as well.
There's a lady over there, I think.
Your point about whether the teaching,
whether the different style of teaching
or the different assessment is actually having an impact,
you said there's no evidence of that.
Where would that evidence come from?
Because the patients are not encouraged.
I don't know how many people here
are encouraged by any doctor to fill in a yellow card.
So it's the doctors themselves
who are actually uncovering these effects.
I take your point and that was really one of the lines
of my concerns about a study in this area.
If we don't have very good mechanism to detection,
then we simply are not going to know the bottom line,
which is actually how do people perform on the ground as doctors.
It's all very well putting them in an exam hall
and showing that they can answer a few questions.
But it's actually how they perform on the ground
and the moment through normal mechanism we don't have that,
we sent out an army of researchers,
we'd still have difficulties,
the resources would be enormous.
But if your point is should patients actually make better use
of the patient reporting system,
which is now available but seemingly not as well publicised
as it might be, yes they should.
Can I just make a second point?
The e-learning website,
will you be including the experiences,
the anecdotal evidence as Professor Healy said?
Will that be included on that website?
I think the honest answer to that is probably not
on the basis that this is a website
to take people from knowing very little bit about pharmacology
to be able to swim in their early years of postgraduate life.
And I think we will do very well just to get them to recognise
the cast iron evidence, let alone throw in a whole lot
of anecdotal evidence from all,
not just psychiatric issues, cardiology, respiratory.
I'm not saying necessarily that it's not worthwhile
and it's important, I listen very carefully to what was said.
We're not dealing here with doctors who are in there
experienced and down the line,
we're dealing with people who are just trying to get to grips
with the basic language and I'm a bit worried
that that would flood the whole system really.
You'd have to give me specific examples,
but I think we are going to be dealing with as near cast iron facts
as we can possibly get.
This young lady I think has got the...
It goes back to what the lady behind me was saying.
I was on the working party that did yellow cards
of patient reporting.
I also do an awful lot of training as part of the organisation
and I use that to say to the people that I'm training,
how many of you know that there is a yellow card
for patient reporting of adverse drug reactions?
And so far, and I suppose since they came out,
I might have trained getting on a thousand people, one.
Well, I had a conversation briefly about this earlier on
just to say that there is a process going on in Scotland
whereby we're trying to publicise things more widely,
but obviously that system is available
and it's just a question of the word getting round.
There's two. One in the front row here.
Oh, sorry.
I've got to declare a vested interest before I make my comment.
I'm a clinical pharmacist working in mental health.
I just want to say I think there's a bit of an untapped resource.
Pharmacists have five years training about medicines
and I think working in a multidisciplinary way,
there's a lot of support we can offer our new prescribers
as they come out onto the wards.
I don't find any argument with me over that whatsoever.
In fact, you are very kind not to point out
that, of course, the clinical pharmacists
probably prevent an enormous number,
a greater number of problems that might arise,
but clinical pharmacists are certainly part
of the educational process for our students.
Could I ask, Simon, if there's any difference
in postgraduate education,
I should say, a graduate entry course education
in medical education,
is there any difference in that problem-based learning
which many medical schools do for those postgraduates
rather than the undergraduate which is often didactic learning?
Have you measured any difference in the therapeutics knowledge
at graduation between those two groups?
Well, up to now, my reading of the literature
I was at a meeting in Canada over the summer
where I addressed just this issue,
is that there's no cast iron evidence
that the problem-based approach beats the didactic approach.
Of course, the studies are very, very small scale,
and now we've kind of got a mixture of courses in the UK.
As John said earlier on,
some medical schools have stuck really to their traditional curriculum
where somebody like me stands up, delivers the knowledge,
goes away and either they're sick or they do some more reading
and take an interest to more active learning
where there's an individual like me sitting in a room
facilitating a discussion as people try to approach the problem.
The idea, the theory, is that the problem-based approach
where you discuss things and find your way through rather than being told
actually reinforces the learning because it's active.
That means an active rather than a passive process.
But the disappointment, as far as my interpretation of the literature
in response to your question,
is I haven't seen any cast iron evidence
that that improves things at the end of the day.
Yes, I'm a server user this time.
I believe there's not enough server user panels on the board
that medical friends could be highly qualified.
So why don't we get server users on the actual panel
or the teaching panel and actually try to get them on and train them
because they are the expert through experience.
You've got all qualifications,
but the qualifications are not as good as the experience.
Sorry, I missed part of it,
but were you saying that actually at the end of the day
experience probably counts for more
than just having a series of letters after your name?
Well, I think that's absolutely true.
At the end of the day, if I'm going to go to a surgeon
to have any procedure done,
I don't actually care too much how many papers
they've published in the medical journals.
I want to know that they've done the procedure
that they're about to do on me 500 times in the last 10 years
rather than just 20.
And the same, I think, is true of prescribing as well.
Oh, well, I wonder why that.
Was that actually that?
I deserve you to have tried to harm yourself before,
tried to commit suicide.
I had to say that I'm an expert through experience
and other people who try to harm themselves
when trying to do serious things like that,
I'll care for people who do things like that.
They're an expert through experience,
they're more qualified than all the people with the...
Sorry, I think I now understand the point you're making.
Yes, I think that if medical meetings
are the type that I normally go to,
included a few more of the kind of testimonies
that were heard from Claire earlier on, Millie,
and I think others,
I think that would concentrate minds a bit more
and just, I think, remind people of actually why they're...
why they're where they are.
And I think medical schools, to be fair,
up and down the country are increasingly trying
to be patient-focused and introduced at an early stage,
patients, real patients and their stories
and what the whole process of medicine
in the wider sense means to them.
And that is very much true also of pharmacology and therapeutics.
I try whenever I can to introduce real stories
as to what's happened out there,
because they stick,
just like the stories I heard today, stuck.
I was just going to say that in Liverpool,
I have a nursing background
and I run the Council for Information on Tranquilisers
and the Depressence Theatre.
In Liverpool, we have medical students
on a placement with us.
And I also do two-half days twice a year
with medical students talking to them
about benzodiazepine addiction
and adverse reactions from SSRIs and so on.
Well, I hope that that is...
the students respond and find that very valuable.
So I didn't see where you were,
because it's very, very difficult.
That kind of learning is invaluable,
but for those that wonder why this just isn't the norm
or medical students can be quite difficult to set up
those kind of learning opportunities and experiences
for 250, or in some cases,
350 students every year.
We're trying to do that. I do 50 at a time.
We're trying to do that in Liverpool
and hopefully elsewhere as well.
We're going to take just two more questions
before we have the panel.
If I've left anybody out, which is inevitable,
if you would care to formulate your question
into paper, then we can address it
as part of the panel discussion.
Oh, hello. I have the mic.
If psychiatric drugs
observed by consultant psychiatrists
to cause adverse side reactions, rare ones,
do the psychiatrists by law
have to notify a governmental monitoring body?
And how can it be checked
that they have notified the authority
by people like me, who's a carer
of a mentally ill person?
Probably Professor Healy's better to answer this,
but my understanding is that there is no legal requirement,
although there is a professional requirement
to do that.
But perhaps Professor Healy will answer that later on.
No legal requirement.
If you could paint the scenario again for us.
Well, if the psychiatrist notices
that the psychiatric drug given to a patient
has a rare, serious side effect,
are you saying he has no legal reason to put it on
one of those yellow cards perhaps?
Well, of course there is a professional
and a moral obligation to do that,
but I don't think there is a legal obligation.
There is no reason why you couldn't assist as a carer
the individual to submit an online report yourself, of course,
but I agree entirely.
Sorry, it's just to say that obviously I'm uplifted
by what you're trying to do
and the changes that are in place.
The Hippocratic Oath is to do no harm first
because that's so fundamental to everything
about caring, medicine, compassion.
Surely there should be more initiatives
into research of this area.
As you say, there's a positive research really
around this such a crucial problem
and it should be highlighted at political level
and maybe if it's highlighted at trust level
at clinical governance and embedded within contracts
for service provision perhaps then you'd get the funding
that you need.
Well, those are all very good points.
I think it's worth saying that within the National Health Service
I trust clinical governance level
big concerns about medication errors
and adverse effects of medicines.
Although there's not so much research going on
on the educational areas I majored on
there's lots of research going on on medication errors
and adverse effects and how they can be reduced
and innovative ideas from any group are always welcome.
