Hello, depriscribers, welcome to another guest blog post! Today we have Dr. Sion Scott from the University of East Anglia (UK) following up with thoughts on the recent blog post regarding healthcare students’ knowledge about deprescribing.
A study exploring medical and pharmacy students’ perspectives regarding medication review and deprescribing within their undergraduate education caught my eye recently. The study generated significant interest and was discussed in a recent Literature Roundup here at the Deprescribing.org Blog. The headline was that only 15% of medical and pharmacy students were familiar with the term deprescribing.
Like many other deprescribing researchers, I took to Twitter to reflect on my own deprescribing teaching. The field of deprescribing research has grown rapidly over the last 10 years and there is now a critical mass of researchers across many universities. Our dual research and teaching roles have facilitated the diffusion of formal deprescribing teaching into healthcare student education.
From my research and teaching experience, there are three key aspects to teaching deprescribing.
1. Deprescribing: What do we mean?
This might seem like an odd one. Surely by now, we’re clear about what deprescribing means? Maybe not. This occurred to me when I delivered my first deprescribing lecture in 2015, and at the time, I was a relative novice to the field.
I came to the lecture prepared for the substantial proportion of students who had never heard about deprescribing; my slides ready with a clear definition and armed with the statistics demonstrating that deprescribing is relatively rare in practice. I was, however, not prepared for the student who put their hand up to tell me that deprescribing happens all the time.
This was actually a really important moment in my research as well as my teaching because it got me thinking; what does existing deprescribing practise look like?
I asked the student to tell me about some of the deprescribing they had observed. Anticoagulants discontinued in patients with a bleed, nephrotoxic medications discontinued in patients presenting with acute kidney injury and so on was the response. They were correct, and I see this all the time in my own practice. The fact is, we would be negligent not to discontinue medication under circumstances of medication-related harm having occurred. However, this isn’t what I had in mind when I started my deprescribing research and teaching. In my mind, I wanted to see deprescribing before harm occurs, not after. But they are both, according to most definitions, prescribing. There is therefore a need to clarify this for our students.
Work to delineate between the two distinct deprescribing behaviours led to coining of the terms ‘reactive’ and ‘proactive’ deprescribing in the literature. Reactive deprescribing is generally routine practice, and there are studies that demonstrate this is the case. Proactive deprescribing, on the other hand, is the goal; however, this is not routine practise and in my view, this is the gap which requires addressing through our teaching.
2. Who do we teach?
Healthcare delivery is a multidisciplinary and team effort, and proactive deprescribing is no exception. The context will of course determine which members of the multidisciplinary team support deprescribing; this will differ between hospitals and primary care for example. Our research at the University of East Anglia found that geriatricians and pharmacists working in hospitals identified nurses, physiotherapists and healthcare assistants as key to supporting the process. They went further and asserted that no professional group can deprescribe on their own; we need to work as a team they said.
My experience of deprescribing teaching thus far is that it is not multidisciplinary in delivery; I only teach the pharmacy students for example. However, other aspects of the curriculum are integrated, with students from other healthcare disciplines learning alongside each through a variety of activities via interprofessional learning initiatives. Given that several professional groups can contribute to the deprescribing process through their own expertise, I would like to see us extending interprofessional learning to include proactive deprescribing, to reflect the realities of practice.
3: What do we teach?
Having refined what and who to teach, the next question is what knowledge and skills do healthcare students need? We know that even for practitioners with years of experience under their belt, deprescribing can be a challenge. Struggling to know which medicines might be appropriate for proactive deprescribing and how to do it are key barriers. Thankfully, there are now several resources available to practitioners to address these barriers including tools to screen for potentially inappropriate medicines (Beers, STOPP and FORTA) and deprescribing guidelines and algorithms to guide practitioners through the process.
In my experience, students respond positively to being introduced to deprescribing resources and being given practical opportunities to try them out using case studies.
However, we know that simply giving people knowledge and skills does not guarantee that they will proactively deprescribe in practice. There are several other barriers to deprescribing in practice, and one of the most challenging to address in the classroom is the uncertainty regarding the potential adverse consequences of proactive deprescribing. Case studies in the classroom do not reproduce the uncertainty regarding proactive deprescribing for a real patient. There is no resource that can with absolute certainty advise that proactive deprescribing is the best thing for a given patient. Dealing with these uncertainties is a real challenge, and whilst we can and do teach healthcare students about inductive and ablative reasoning to inform decision making, experience and learning from others over years of practice is likely the key enabler.
Teaching healthcare students about proactive deprescribing is increasingly important to make this become routine practice. Introducing students to the concept of deprescribing and providing opportunities to utilize the range of deprescribing resources represents substantial progress since my undergraduate days. It is probably unrealistic, and unfair, to expect newly qualified healthcare practitioners to graduate as masters of proactive deprescribing. However, incorporating deprescribing teaching into their education may equip them to make the most of the experience they gain from their early practice years.