Robert W. Donnell, MD: Exploit Available Resources and Knowledge
Physicians face a daunting task in achieving and maintaining competence in drug therapy. Essential underpinnings of rational drug therapy that are taught in medical school, including physiology, pharmacokinetics, and pharmacodynamics, are all too easily forgotten and must be regularly reviewed. New drugs are appearing at a rapid rate, and an increasingly bewildering array of drug interactions exists. Moreover, postmarketing reports of adverse events occur almost daily. It's no surprise, then, that suboptimal prescribing practices are widespread. These deficiencies, most of which are not "errors" in the usual sense, take several forms.
One of the more common problems in drug prescribing is underutilization of evidence-based therapies. For example, despite strong evidence to support the use of beta blockers and angiotensin-converting enzyme (ACE) inhibitors in heart failure, and anticoagulants for prevention of venous thromboembolism, these medications are prescribed at an inordinately low rate.[14,15,16] Although dissemination and accessibility of evidence-based guidelines have improved with the advent of electronic media, cognitive barriers to clinical adoption remain to be addressed in an effective manner.
Faulty prescribing often takes the form of failure to observe safety warnings and contraindications in product labeling. In a study of hospitalized patients taking metformin, for example, 27% were given the drug despite at least 1 absolute contraindication, and substantially more received it in violation of known safety precautions. Fortunately, metformin proved to be a forgiving drug with a low incidence of adverse effects.
Other drugs, though not inherently bad, are not so forgiving. The popular antimotility agent cisapride caused life threatening cardiac arrhythmias when prescribed with interacting drugs or to patients susceptible to its adverse electrophysiologic effects. Adverse prescribing persisted despite regulatory action by the FDA and "dear doctor" letters, ultimately leading to the product's withdrawal. In fact, such contraindicated prescribing has led to the demise of several good drugs, thus depriving patients of beneficial therapies.
For some highly nuanced drugs, particularly those with a narrow safety margin, optimal prescribing may be largely a matter of expertise. Warfarin, for example, performs better in the hands of experts; a recent review found that patients were more likely to have nontherapeutic international normalized ratios in community practice settings than in the settings of clinical trials or anticoagulation clinics.
Clearly, the solution like the problem must be complex and multifactorial, encompassing not merely knowledge about drugs but the broader issues of basic science, evidence-based medicine, and clinical expertise. The need for better education in pharmaceuticals spans medical school, postgraduate training, and the physician's commitment to lifelong learning.
One of the hottest controversies related to this issue concerns the role of the pharmaceutical industry in medical education. Although I reject as extreme and counterproductive the position that doctors should shun drug company representatives, I believe doctors should not rely on drug company materials as a major source of education. Drug company reps may provide useful resources such as product labeling and copies of evidence-based guidelines, but most of their materials are promotional, tending to inflate the benefits of their products. In today's electronic age, better sources of information are readily available.
Since each individual physician knows best wherein his or her educational needs lie, it would be inappropriate for me to provide an all encompassing list of best resources on drug prescribing. Here are a few I have found helpful: the pharmacology chapter of an internal medicine textbook provides a useful basic review. An excellent resource on evidence-based medicine and critical reading of the medical literature is the American Medical Association's Users' Guides to the Medical Literature. Useful drug "look up" resources include Mosby's Drug Consult and RxList. Finally, there are many drug interaction tools available online, including Medscape's Drug Interaction Checker.
Medscape Med Students. 2006;8(2) © 2006 Medscape
Cite this: How Can Physicians Stay Current on Prescription Drugs? - Medscape - Aug 30, 2006.