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Doi:10.3402/meo.v20.27097

Medical Education Online æ A study to enhance medical students' professionaldecision-making, using teaching interventions oncommon medications Jane Wilcockand Janet Strivens2 1Faculty of Health and Life Sciences, Institute of Learning and Teaching, School of Medicine,University of Liverpool, Liverpool, UK; 2Educational Developer, Centre for Lifelong Learning,University of Liverpool, Liverpool, UK Aim: To create sustained improvements in medical students' critical thinking skills through short teachinginterventions in pharmacology.
Method: The ability to make professional decisions was assessed by providing year-4 medical students at a UKmedical school with a novel medical scenario (antenatal pertussis vaccination). Forty-seven students in the 2012cohort acted as a pretest group, answering a questionnaire on this novel scenario. To improve professionaldecision-making skills, 48 students from the 2013 cohort were introduced to three commonly used medications,through tutor-led 40-min teaching interventions, among six small groups using a structured presentation ofevidence-based medicine and ethical considerations. Student members then volunteered to peer-teach on afurther three medications. After a gap of 8 weeks, this cohort (post-test group) was assessed for professionaldecision-making skills using the pretest questionnaire, and differences in the 2-year groups analysed.
Results: Students enjoyed presenting on medications to their peers but had difficulty interpreting studies anddiscussing ethical dimensions; this was improved by contextualising information via patient scenarios. After8 weeks, most students did not show enhanced clinical curiosity, a desire to understand evidence, or ethicalquestioning when presented with a novel medical scenario compared to the previous year group who hadnot had the intervention. Students expressed a high degree of trust in guidelines and expert tutors and feltthat responsibility for their own actions lay with these bodies.
Conclusion: Short teaching interventions in pharmacology did not lead to sustained improvements in theircritical thinking skills in enhancing professional practice. It appears that students require earlier and morefrequent exposure to these skills in their medical training.
Keywords: critical thinking; professionalism; prescribing; antenatal pertussis vaccination; patient centredness; medicaleducation Responsible Editor: Professor Lynn Yeoman, Baylor College of Medicine, USA.
*Correspondence to: Jane Wilcock, Faculty of Health and Life Sciences, Institute of Learning andTeaching, School of Medicine, Ground Floor, Cedar House, Ashton Street, Liverpool L69 3GE, UK,Email: [email protected] Received: 27 December 2014; Revised: 27 April 2015; Accepted: 30 April 2015; Published: 5 June 2015 Professionalismdefinesthevaluesofadoctorand effectiveness of treatment options, and that decisions is set out by the General Medical Council (GMC) should be arrived at through assessment and discussion for today's UK doctors (1); among these is ‘make with the patient' (2).
the care of your patient your first concern'. Duties of a Justifying decisions requires an understanding of con- Doctor in Good Medical Practice (1) also states ‘you temporary knowledge, and whilst advances in medical are personally accountable for your professional practice understanding, therapies, and the world wide web have and must always be prepared to justify your decisions made large numbers of research articles available from and actions'. This is further discussed, under Good clini- around the world, it also makes individually knowing cal care 16e, in the ‘GMC document Medical students: all available research, or even knowing best resources, professional values and fitness to practice', which states less likely. For example, hypertension has been treated ‘treatment should be based on clinical need and the since the mid-1980s (3). A search on the university online Medical Education Online 2015. # 2015 Jane Wilcock and Janet Strivens. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (, allowing third parties to copy and redistribute the material in any medium orformat and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
(page number not for citation purpose) Jane Wilcock and Janet Strivens library for terms ‘primary prevention of hypertension' from 23% in 1980 to nearly 40% in 2000'. The National gave 13,426 results in 2014 and on ‘hypertension' reveals Patient Safety Agency (11) reports that 6.5% of hos- 1,336,878 results. Most medical students still prefer to pital admissions were related to medication issues, of read textbooks in the UK, and there is understandable which 9% were definitely preventable. Drugs most poor discrimination about which online resources they use commonly associated with harms were aspirin, diuretics, (4). The development of internet-supported authorities, warfarin, and non-steroidal anti-inflammatory drugs, reviews, guidelines, and risk scores help to provide usually causing gastrointestinal haemorrhage. The Medi- solutions to clinical scenarios, but at the expense of cines and Healthcare Products Regulatory Authority individual critical thinking skills, that is, students may received 297 reports of fatality to warfarin (an antic- develop a knee jerk learnt solution to a prescribing issue oagulant) between 1963 and 2008 (12). About 700 deaths rather than learning to think through the problem.
per year in the UK are considered to be directly attri- Maudsley and Strivens (5) noted that ‘British under- butable to medications and also preventable. The GMC graduate curricula have long struggled to prevent factual publication ‘Good practice in prescribing and managing overload from suppressing critical thinking'. Facione medicines and devices' (13) aims to improve prescrib- et al. (6) identified in professional decision-making ‘pro- ing skills. In addition, a Prescribing Safety Assessment blem resolution', which may be taught through guidelines, examination has been introduced to medical schools and ‘problem framing'. The student who has framed throughout the UK, so medical students should be gaining the wrong professional question may reach the wrong understanding of evidence for drug use, indications, and resolution. Rather than train students to every eventuality, starting to critically assess their prescribing decisions.
university education should encourage students to ask It is on this background that I chose to discuss medi- professional questions of the specific context, so that stu- cations as a vehicle for improving professional decision- dents frame questions which become transferable across making. In creating future professionals, medical students different scenarios. Facione identified critical thinking and are encouraged to act as active self-directed learners to inquisitiveness as two of seven personality traits associated build on prior learning, explore known concepts, and with good skills in problem framing and problem solving, analyse new knowledge and experiences (14). The role of and these should be encouraged. Students need to think the tutor is to discover what the student already knows objectively, analyse evidence-based medicine (EBM), and then act as a mentor to provide ‘scaffolding', which justify the beliefs they are developing, and share those allows the students to work out best ways to learn with their peers. I share Winters and Echeverri's (7) view of autonomously. Using these principles in this study, the the teaching of EBM which is described as: 1) ask the students were offered constructivist learning opportunities clinical question; 2) search for best evidence; 3) critically to progress from novice to life-long learners and improvers appraise the evidence; 4) integrate the evidence into as clinicians.
practice; and 5) evaluate the outcomes.
Winters and Echeverri (7) identified barriers to teaching EBM as: lack of knowledge, belief, and skills regard-ing EBM; lack of critical appraisal skills; and taking too Pretest and post-test study: student critical thinking much on. Prescribing scenarios are particularly complex as using antenatal pertussis vaccination scenario there are medical system issues, for example, renal func- To explore approaches to problem solving with year-4 tion, interactions, safety, convenience, monitoring, length students in the 2012
2013 academic year, I gave them of therapy, changes in patient conditions, balances be- a short questionnaire exploring student attitudes and tween short- and long-term outcomes, costs, and patient knowledge of antenatal whooping cough (pertussis) vacci- views. After analysing information, students and doctors nation (Appendix 1). The questionnaire was wide ranging need to create outcomes. Outcomes are described by Porter so that students would not try to predict tutor-wanted (8) as inherently condition-specific, multidimensional, and responses. The questions relating to the study are numbers factors requiring weighing against each other. This moves 1, 2, 5, 6, and 12. Answering it was voluntary, 47 students Winters' EBM skills into ethical areas. For this study, returned the form and 1 student did not.
I advocated the Beauchamp and Childress' ethical princi- In April 2012 in the UK, the Health Protection Agency ples (9) of beneficence, non-maleficence, autonomy, and declared a level 3 incident response to rising levels of justice because the students had been taught these in pertussis in neonates and recommended vaccination of previous years.
women between 28 and 38 weeks of pregnancy with a Prescribing was chosen as the professional thinking vaccine containing pertussis, diphtheria, and tetanus from exemplar because of increasing patient co-morbidities October 2012 (15). Antenatal vaccination has little pre- and polypharmacy, risking harms, side-effects, and inter- cedent; in 2008, flu pandemic antenatal influenza vaccine actions. Hagstrom et al. (10) surveyed patients and found was used, and postvaccination surveillance suggested a that individuals declaring a chronic disease ‘increased small risk of narcolepsy related to Pandremix vaccination (page number not for citation purpose) Enhancing medical students' professional decision-making in offspring. Little is known about actual risk, in vivo always be right but that there was an effort at best vaccination transfer from mother to foetus, and potential problems with adjuvants (16). Pertussis vaccine, givenas Repevax, contains acellular pertussis, diphtheria, teta- The three scenarios used were: aspirin after a heart attack, nus and polio, formaldehyde, glutaraldehyde, neomycin, the use of tiotropium handihaler in chronic obstruc- streptomycin, polymyxin B, or bovine serum albumin.
tive airways disease (COPD), and use of simvastatin to Antenatal vaccination with pertussis was therefore used reduce cholesterol in patients with coronary heart disease as a scenario to which students would not have an ‘off (CHD). Over the 6 weeks, students became accustomed the peg' response, guideline, app., or e-resource readily to the structure of the teaching, to critically analysing available. This pretest study was in conjunction with EBM, and discussing ethical aspects of prescribing.
another clinical tutor to gain necessary numbers. At the To offer a variety of tutor methods to allow students next meeting, students were asked; ‘How do you feel about to find EBM resources, practice critical analyses, and performing a new skill?' and ‘What would you want before to model their behaviour on my interventions, I asked doing a new skill?' in order to encourage a discussion a student in each group to volunteer to tutor on another of attitudes and critical thinking
themes were then medication of their choice, or suggested by myself.
brought together by the two tutors.
I helped students find respected EBM resources online This same questionnaire and discussion was undertaken if asked. They were asked to follow the same tutoring as a post-test study in the 2013
2014 medical student format. Each of the six groups, therefore, had a further group but only by one tutor, 8 weeks after the prescrib- three teaching interventions over 6 weeks but by peers.
ing interventions and the 2-year group results com- A total of six medications were discussed over the study pared. The expected outcome was that the second group for each group.
would display improved critical thinking and professional During student presentations, I made notes using a table to note if EBM and ethical issues had been discussed.
I was keen that students remained autonomous thinkersand that I did not create another ‘guideline' on how to think so I encouraged questions and problem framing The intervention group was six groups of 6
10 fourth rather than answers.
year medical students whom I tutored for 1 day every After the six interventions there was an 8-week gap in 2 weeks throughout their academic year 2013
2014. At which we did not discuss EBM and critical thinking three meetings, 40-min teaching topics were introduced unless initiated by students. I then administered the post- on the commonly used medications: aspirin, tiotropium, test part of the study as above.
and simvastatin (Appendices 2
4). The teaching was The study had ethical approval from the university subdivided into four parts: (study 201208117). Students were not consented into thestudy for two reasons: first, it was impossible if students 1. Tutor and student discussion of facts about the did not consent to exclude them from participation as chosen drug. A table of important facts was estab- the study took place in usual teaching sessions. Second, lished to improve and uniform baseline knowledge.
if students were consented into a study to look at ethical 2. Tutor questioning about drug effectiveness in a behaviour they might perform to the study outcomes specific common scenario to verbalise drug efficacy rather than offer true opinions of patient problems and beliefs among students. Presentation of a major management. At all times, participation in discussion, trial in abbreviated form, outlining method of study,with headline outcome numbers of benefits and teaching peers, and filling in the final questionnaire was harms. Students were asked to respond to the EBM voluntary among the students.
3. Students were asked ‘what other considerations are there in prescribing, beyond EBM, and the factsabout the drug?' This was frequently rephrased, due to lack of response, to ‘can you tell me any When students asked about drug information, they ethical principles that could be used in deciding wanted information as found in the British National whether to prescribe?' The students recalled the Formulary (BNF). When asked about further information Beauchamp
Childress four ethical principles and they asked about serious interactions, illnesses that they were encouraged to relate these to the medication.
should aware of when prescribing, overdose, effects in 4. A variety of scenarios were discussed in which pregnancy, and cost. Students did not ask about EBM different prescribing judgements might be made of action, EBM of benefits, or harms initially; although with the understanding that no one answer would they learnt this over the three cycles and were interested.
(page number not for citation purpose) Jane Wilcock and Janet Strivens Students were asked how effective they thought the need to take this drug, doctor?' Only one student discus- drug was in the scenario and were encouraged to guess.
sed that a 3% reduction in death from heart attack was The figure for benefit of aspirin in preventing further highly significant across the UK population, others were heart attack or angina in secondary prevention patients likely to say, ‘Well, I wouldn't take it'. One student sug- was estimated as highly effective, mode 70% effective
gested placebo drug use. Most students wanted to when encouraged to round down the lowest guess was prescribe amoxicillin despite contrary evidence of benefit.
17%. Students were very surprised at the lack of magnitude Responses to not prescribing amoxicillin were ‘get a good of efficacy of aspirin and other medications. They vastly lawyer', ‘explain the EBM', ‘get a sputum sample or overestimated effect and underestimated harm. Reactions a CXR', ‘stop doing medicine', ‘prepare for aggression', to this were, ‘so medications aren't as good as we thought ‘go to Spain and stock up', and ‘self-treat with home they would be' and ‘I wouldn't take it'.
remedies'. There was some discussion about public health Students enjoyed talking about trials but were not campaigns. In discussing autonomy and amoxicillin use, used to handling information and made simple errors in one student told the group, ‘I would tell them they had summating patient numbers, dropouts, and percentages to take it or they would die'. When asked if that would be and were unable to critique studies accurately. After the true the reply was, ‘Not really'. A response in relation to first session, I gave them printouts so that they had the ethics was, ‘It's really confusing'. There was therefore figures before them as well as on the white board and concern that unless guidance was followed patients might could take them home.
litigate or complain. Some students' prescribing prefer- Students did not consider ethical principles, for exam- ences were directed by their own illness experience despite ple, benefits, harms to patients and society, and autonomy the evidence. A discussion about not prescribing creating without prompting. They struggled to use these in an patient aggression led to a student-observed anecdote abstract manner and improved when patient contexts were of a patient becoming aggressive in a GP consultation.
used. When initially asked to consider ethical principles Students lacked non-prescribing consultation skills and in prescribing, two comments were, ‘Oh, is this an ethi- management plans and wanted to share concerns about cal question then?' and ‘Is it the society, groups, and individuals stuff ?' During the gap of 8 weeks, I did not discuss prescrib- Students chose to present on amoxicillin, ramipril, ing issues, EBM, or ethics unless they came up in case metformin, citalopram, ibuprofen, and amlodipine. Stu- presentations. On one occasion, a student gave a patient- dents generally followed the tutor format but it was centred presentation but did not connect the patient's unusual to have the evidence well-presented, and errors warfarin (an anticoagulant) prescription to the patient's were common. Students suggested resources like National complaint of haemoptysis: this student had not criti- Institute for Clinical Excellence (NICE) clinical guidance, cally assessed the patient's medications. Students did not Health and Social Care Information Centre, found their continue to discuss EBM or ethics in presenting case own references, and went to a lot of trouble to review the histories. Compared to previous years, however, I found information. Interpretation was variable, and some student- the case presentations contained more patient information tutors could not distinguish absolute risk reduction from about function and views.
relative risk reduction, so overestimated drug effects.
Students used PowerPoint and handouts. Some students Pretest and poststudy questionnaires rejected suggested trials in favour of other meta-analyses, In the pretest study, 47 students handed back the ques- one student introduced Forest Plots. Two students intro- tionnaire, one did not.
duced groups to Patient Decision Aids. A few stu- In the post-intervention group after 8 weeks, 42 stu- dents used numbers needed to harm (NNH) and numbers dents (six students were absent due to illnesses) were needed to treat (NNT) as markers of effect. One student asked to complete the questionnaire and they all discussed with the group about clinical trials and lack of handed them back. The full results of the 2012
2013 grey (unpublished evidence) and called on the group to and 2013
2014 year groups' responses are in Appendix 1.
sign the petition at Students found The results relevant to the prescribing intervention are Patient Decision Aids, NNH, and NNT most effective.
Student-tutors who presented varying patient scenarios Responses to question 1 confirmed that this was a novel created more discussion with peers about harms and scenario for these medical students, which was the inten- benefits than those who did not contextualise prescribing tion of the study. Ninety-five percent of students post interventions were dissatisfied with their knowledge of Students had difficulty formulating ethical questions.
antenatal pertussis vaccination yet 88% (question 2 parts Student-tutors and I resorted to asking the group personal 1, 2, and 3) would give the vaccination; this figure is 87% questions, for example, ‘What if I were to give you this in the pretest group. The only clear disparity between drug tomorrow?' and ‘What if the patient says, do I really the pretest and post-intervention students' responses (page number not for citation purpose) Enhancing medical students' professional decision-making Table 1. Results of survey into student attitudes to antenatal pertussis vaccination pretest and post-intervention groups Non- intervention group (pretest); Post-intervention group (post-test); % of students choosing these % of students choosing these options (total number of options (total number of Statements from questions 1. parts 3 and 4 Dissatisfied with their knowledge of vaccination of pertussis in pregnancy 2. parts 1 and 2 Would vaccinate in pregnancy Would not be confident to vaccinate but would do so after checking with nurse or online as it is a government recommendation 5. parts 1 and 2 Had concerns regarding maternal harm in Were unsure whether they had concerns or not, about maternal harm 6. parts 1 and 2 Had concerns about harms to the baby Were unsure whether they had concerns or not, about harm to the baby was that post-intervention students were more likely to and we should think about the vaccination but in practice have concerns about maternal harm. There was some small change in post-intervention students being less Therefore, short teaching interventions in pharmacol- certain about concerns of foetal harm in vaccination.
ogy did not lead to clear sustained improvements in In the free text boxes, students from both groups medical students' critical thinking skills in enhancing commented that they knew nothing about pertussis professional practice. Barriers to conversations about vaccination in pregnancy and would like to know more.
professional decisions related to poor EBM interpre- The preliminary group made 17 comments and the study tation skills, reluctance to change practice, and not group made 28 comments (question boxes 1, 2, 5, 6, and recognising common prescribing scenarios as having 12, Appendix 1), a number commenting that they required ethical dimensions.
more information in order to make decisions. Neverthelessin both groups, despite misgivings, students overwhel- mingly would give the vaccination if asked.
This study confirmed that professional thinking skills Two weeks later the post-intervention students were need to be taught explicitly in the medical curriculum at an given the results above and asked two questions ‘How do early stage and be developed over the years. Donaldson you feel about performing a new skill?' and ‘What would et al. (18) reported on students who had been asked to you want before doing a new skill?' bring ethical cases for discussion and found that many All groups were clear that they would trust the focused on legal obligations rather than the morality of expert asking them to give the vaccine. Responsibility for what should be done. In addition, he found students long-term side-effects due to vaccination would lie with identified ethical issues as occurring at times of conflict in guideline authorities. A few students mentioned risks of medical management and that students can describe ethi- anaphylaxis but, when asked if they knew if adrenaline cal issues but were not used to applying them in decision- for anaphylaxis would be present, said they would not making. This is in agreement with this study. Students check but assumed so. They stated that anaphylaxis require practice in logic and reasoning skills and placing was rare and that the nurse would be trained to manage them in a value-laden practice, which is patient centred; it. Rates of anaphylaxis are rare at about 1 in 1,000,000 this could be encouraged by experts vocalising their decision- vaccinations (17). Students were pleased to take on new making processes more explicitly. The apprentice
master skills, though occasionally anxious, but did not feel a model of clinical placements in undergraduate medical need for EBM or ethical consideration. Comments made education
relies on students mimicking expert behaviour.
were ‘we are asked to do new things all the time so just get Students are rarely asked their views in scenarios (parti- on with it'. This response was exactly the response of the cularly when best practice is not obvious or not guideline pretest student groups. The only difference was that some driven), have intellectual conversations about best prac- of the post-test students stated that ‘I know it's wrong tice, or allowed to propose alternative management plans.
(page number not for citation purpose) Jane Wilcock and Janet Strivens A number of student-tutors emailed in advance or incidence or prevalence of harms and benefits of com- asked in the presentation if they were ‘doing the right monly used medications and so made highly inaccurate thing'. Freeing students to appreciate that there was no assumptions. Medical students need to contextualise right and no wrong answer to problems led to an increase facts, evidence, and ethical information and consider in maturity of discussion with consideration of patient patient individual factors before arriving at decisions.
values in case and topic teaching discussions until the end It may be that students are able to consider ethical issues of the year.
but reserve judgement without more information and The study was limited by time, the intervention was find abstract decision-making unsatisfactory. The early limited to 40 min and this particularly limited the feedback development of professional questioning would help stu- that could be given to the student-tutor contributors, dents to mature. I think that tutors should encourage and general end-of-session feedback to emphasise learn- experimental thought and error to gain best ways of ing points or provoke further reflection. There was only decision-making and best decisions which then translate myself delivering the study and assessing the outcomes; into good decisions in clinical practice, for example, this study would have been much stronger with peer-tutor good prescribing decisions. Professional questioning review and a peer-tutor in class observation making a would allow students to have an overview of medical note of emerging themes. There may have been effects management. In this study, medical students were unable of my own values on topic teaching and interpretationof comments, which might affect the validity of results to progress in answering therapeutic questions as they and identification of themes. It was difficult to listen to hesitated at the EBM content, lacked skills in interpreta- students facilitating the group, respond when required, tion and were then reluctant to discuss an overview of and make observational notes about content. Using direct patient prescribing without this. This inability to develop quotations allowed some accurate recording of activity.
overarching professional views meant that most students A form created to record student activity was not easy to were willing to give vaccinations in novel circumstances use or adequate in recording themes.
(pregnancy) despite a lack of knowledge and were not The study benefitted from using small groups who had willing to take responsibility for their decision.
already met on five occasions with tutor-led and peer-peer Skills training and resource pointing to interpret EBM teaching of topics, so the study slotted into the day. As to decide best evidence in the specific patient circum- there was already trust between tutor and small groups, stances could be fixed within a framework of indivi- the reflections were honest. Starting the study towards the dualised patient scenarios with ethical-based values in end of the first term meant that stretching the student order to foster open appraisal of benefits and harms learning to encompass professional thinking felt natural which might run counter to preconceptions. This requires over the year. Having all students blinded to the study time to let students practice skills over a number of meant that discussions were frank and honest and is a scenarios during all of their training
in this way, major strength of this study. In developing a number of students can choose to develop attitudinal and epistemo- teaching interventions, the students were able to evaluate logical change. Students should be encouraged to explore medications, scenarios, online resources, and practice their understanding that outcomes can be uncertain; skills improvement over a number of months.
influenced by evidence, context, and patient choice; and The choice of antenatal pertussis vaccination could be multiple. This requires freeing up medical curriculums be criticised as relating professional thinking to a skill into less content-heavy syllabuses and allowing experi- in which instructional method might be more usual but mentation of ideas in class and on clinical placements.
I believe that all medical actions should belong to a This requires a change in tutor culture and timing; reflective practitioner who is able to consider whether in practice, it is easier to train a medical student to undertaking the procedure is in the best interests of the identify a problem and select a known accepted response.
patient. In setting up professional scenarios, practicebecomes quickly outdated and tutors require signposting Is this what society would like from its doctors? Does it to resources to get started and need to create a repository provide the best care? If it does then it is possible that of respected resources, clinical cases using context, in- medical school training could be provided as a distance formation, and ethical aspects, to create decisions and learning knowledge base and later clinical expert
quality assurance and reflection of these.
apprentice model.
In conclusion, students were not able to transfer skills The authors acknowledge Dr. Janine Riley for acting as support developed in professional decision-making to a novel med- investigator to the pretest group and Dr. Ray Fewtrell for help and ical scenario. They have no in-depth knowledge of likely (page number not for citation purpose) Enhancing medical students' professional decision-making Conflict of interest and funding 9. Beauchamps and Childress. Principles biomedical ethics. 5th ed.
OUP, 2001; explained at The four principles of biomedical The authors have not received any funding or benefits ethics. Available from: from industry or elsewhere to conduct this study.
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(page number not for citation purpose) Jane Wilcock and Janet Strivens Appendix 1.
Responses to Whooping cough vaccination in pregnancy questionnaire year 4 medical studentsPretest year 2012
2013 in bold and post-test study group 2013
2014 cohort in italicsWhooping cough vaccination in pregnancy. There were 47/48 replies 42/48 repliesPlease assume your area GP StR1 and a pregnant woman attends your next surgery session when replying.
1. Do you feel knowledgeable about whooping cough vaccination in pregnancy? Please delete the responses not applicableleaving the response you most agree with.
1. I am very knowledgeable about whooping cough vaccination in pregnancy 2. I am satisfied with my knowledge about whooping cough vaccination in pregnancy 3. I am not satisfied about my knowledge about whooping cough vaccination in pregnancy 4. I feel I lack knowledge about whooping cough vaccination in pregnancy Pretest comment ‘I am unsure about the timings' Post-test comments ‘I do not know if it is safe in pregnancy' ‘I do not know anything about whooping cough vaccination in pregnancy' ‘I have never heard of it' ‘I am unsure about time-frames and risks' 2. What is your personal position about vaccinating a pregnant woman against whooping cough?Please delete the responses not applicable leaving the response you most agree with.
Pretest Post-test 1. I have already personally vaccinated a pregnant woman against whooping cough myself 2. I am happy to vaccinate the pregnant woman myself but have not yet had an opportunity to do so 3. I would not feel confident in vaccinating the pregnant woman myself but would do so after checking details with my nurse or online as it is a government recommendation 4. I am not happy about vaccinating a pregnant woman against whooping cough at present 5. I would not vaccinate a pregnant woman against whooping cough Pretest comments: ‘Is it needed if the mum has had childhood vaccination?' ‘I am unsure about the indications or reasons not to vaccinate' ‘I am not confident as I am not sure it is safe?' ‘It is not a live vaccine so I am happy to vaccinate' Post-test comments: ‘I would check with an expert and contact the national vaccination programme to gain advice' ‘I would vaccinate if my GP or nurse tells me it is standard practice' 3. Should women post-partum be vaccinated against whooping cough?Don't know 23. 11 Yes 12. 14 No 4 11Comments: ‘I would have to look this up'‘I have no knowledge re evidence for efficacy'‘The benefit is for the baby so there is no benefit in giving post-partum vaccination to the mother'‘Vaccination should be given if there is enough evidence that it is beneficial and cost effective, etc.' 4. a) Do you understand the mechanism of vaccination in pregnancy?Don't know 4. 3 Yes 11. 11 No 24. 26b) Does the vaccination cause maternal antibody production and transfer of these antibodies to the foetus or does itcause the foetus to produce antibodies?Maternal antibodies are transferred 17. 23 Don't know 18. 14 Both 1 Foetal produces antibodies 3. 3Comment: ‘I would have to look this up'c) Would an understanding of the science of antibody transfer and production across the placenta be something youwould be interested in?Yes 35. 38 No 5. 3 Maybe 2Comments: ‘I definitely need more teaching on this' ‘I am a bit interested but only in the clinical relevance'‘This is an important topic and with anything in medicine patient lives are at risk therefore doctors should always considerthe consequences'.
(page number not for citation purpose) Enhancing medical students' professional decision-making 5. Have you any concerns about harm to the woman? Please delete the responses not applicable leaving the response youmost agree with.
1. Yes I have a lot of concern about harm to the woman 2. Yes I have some concerns about harm to the woman 3. I am unsure whether there may be harm or not to the woman 4. I am fairly sure I have no concerns about harm to the woman 5. I have no concerns about harm to the woman Pretest comments: ‘There may be a risk of flu like illness and anaphylaxis' ‘There may be a risk of flu and anaphylaxis like any vaccination' ‘It might depend if it is a live vaccine (I have some concerns)' Post-test comments ‘I do not know what harm the vaccine can cause and whether this would be different in a pregnant woman' ‘I do not know about vaccinations in pregnancy' 6. Have you any concerns about harm to the baby? Please delete the responses not applicable leaving the response youmost agree with.
1. Yes I have a lot of concern about harm to the baby 2. Yes I have some concerns about harm to the baby 3. I am unsure whether there may be harm or not to the baby 4, I am fairly sure I have no concerns about harm to the baby 5. I have no concerns about harm to the baby Pretest comments: ‘I think there is a very small risk to the baby as with any vaccination it is not 100% safe' ‘I would need to read more about it' Post-test comment: ‘I do not know if it is harmful to the baby or not' 7. a) Do you think GPs are best placed to vaccinate pregnant women?Yes 31 32 No 3 3 Don't know 4 2b) Who do you think should be doing this procedure?Don't know 3. 2 Midwife 9. 7 Practice nurse 15. 12 GP 18. 26 med student 1. Obstetrician 2. 5 HealthVisitor 1. Paediatrician 1 anyone appropriately trained 3Comment: ‘I think midwives would be more cost effective than GPs' 8. State what you think is the national uptake rate of whooping cough vaccination in pregnancy at present in%?5
90% range. 5
80% range. 5
10%5. 15
30%14 16 31
50% 5 3 51
60% 5 59. If you were to vaccinate in your next surgery what is the name of the vaccine you would use?Don't know 30 46 DTP and pertussis 1. Varied incorrect 5 10. Have you done any routine baby immunisations in the last 12 months? Y 7 3 No 33 36 11. Would a pregnant woman attending you be given written information about whooping cough vaccination? Y 25 34No 2 Don't know 13 8 12. Please write any comments below which would help me in understanding student thoughts, feelings and approaches towhooping cough vaccination in pregnancy including any further training you may have wanted.
Pretest comments: ‘I think more teaching should be given on issues such as this which change and have a big impact'‘I have received no formal teaching on this but know it is offered but not sure when'‘The only contact/info I have had re this has been through personal attendance at a GP surgery when I picked up a leaflet ‘I don't have any knowledge of this' Post-test comments: ‘I know very little about this and would like to know more'‘I don't think medical students can give vaccinations' (page number not for citation purpose) Jane Wilcock and Janet Strivens ‘I don't know much about it'‘This is an area I have little knowledge of'‘I would like to have more information on the effects of vaccinations in pregnancy in general, not only whooping cough'‘I have no knowledge so do not feel I can give the vaccine'‘I have no idea what this is and want to know the benefit to the baby mainly'‘I know very little about this'‘I do not know enough about whooping cough vaccination in pregnancy to make decisions upon giving it or not giving it'‘I need more education surrounding this'‘If I knew more about it and there was the right evidence I would be happy to give it'‘I have never heard of it'‘I honestly don't know anything about this topic' Appendix 2. Tutor sheet regarding aspirin (November 2013) Should patients who have had a heart attack take long-term aspirin? At present students would be considered to be ‘doing well' if they identified that the UK guideline is to provide patients with aspirin after a heart attack (MI) and be able to write this prescription safely, identify that it may cause wheeze or peptic ulceration and understand that it acts as an antiplatelet.
During a short teaching intervention students will be guided to consider the patient perspective: Consider BNF facts about aspirin How useful is it to the patient? What are the risks of harm to the patient? Drug use is considered in terms of Beauchamp and Childress' 4 ethical principles: In order to consider ethical issues students require more than guidelines, they require an evidence base. Evidence bases can found in NICE full guidelines and patient decision aids, also provided by NICE (previously by the National Prescribing Centre). There are other useful sources which students may subsequently research.
So for the scenario above the evidence would be: Do good for the patient: Aspirin is known to reduce death from MI and cardiovascular events in patients who have had a MI. A 1970s study suggested that placebo (no aspirin or anticoagulant) patients had a death rate of about 8.5% over an average follow up of 22 months, reduced to 5.8% by quite high dose aspirin.
Do no harm to the patient: The CURE study had a rate of major bleeding in non-ST elevation (less severe) MI patients of 2.7% on aspirin.
Students may want to think about definitions of major bleeding; general non-adherence rates for patients on long-term therapy and reasons for these; changes in patients' susceptibility to harms over their lifetime.
Patients' informed decision-making: Given the evidence, how would the students as doctors present the evidence to a patient? Is the evidence what they would have expected themselves? Justice to the patient and to society: Students and doctors overestimate the benefits of medications at an individual level but a nearly 3% reduction in second MI and angina after a first MI throughout society (28% of all deaths in the England and Wales in 2012 were due to CHD and stroke) is very significant.
The students would be signposted to relevant resources by the tutor initially.
Appendix 3. Tutor sheet regarding tiotropium (December 2013) How useful is tiotropium for patients with COPD? At present students would be considered to be ‘doing well' if they identified that the UK guideline is to provided patients with tiotropium with COPD and be able to write this prescription safely, identify that it may cause a dry mouth and understand that it acts as an During a short teaching intervention students will be guided to consider the patient perspective: How useful is it to the patient? What are the risks of harm to the patient? Drug use will be considered in terms of Beauchamp and Childress' 4 ethical principles: Facts: indication: maintenance COPD Cautions: if eGFR B 50 ml/min, benign prostatic hypertrophy (BPH), bladder outflow obstruction, susceptible to acute angle eye glaucoma.
(page number not for citation purpose) Enhancing medical students' professional decision-making Side-effects: dry mouth, constipation, tachycardia, cough, paradoxical bronchospasm, palpitations, AF, headache, dizzy, urinary retention, blurred vision, dyspepsia, taste disturbance.
Interactions: discuss liver metabolised drugs In order to consider the ethical issues here the students require more than guidelines. They require an evidence base. The evidence bases can found in NICE full guidelines and patient decision aids, also provided by NICE (previously by NPC). There are of course other sources that may be useful and it will be up to students subsequently to find best evidence.
So for the scenario above the evidence would be: A long-term evaluation of once daily inhaled tiotropium in COPD; R. Casaburi et al. European Respiratory Journal Feb1, 2002, vol. 19 no 2 p. 217
224.
This is a major reference used in initial decision-making by NICE in including tiotropium in COPD guidance.
British Thoracic Society (BTS) guidelines also refer to NICE guidance.
This was a double-blind placebo randomised trial of inhaler without tiotropium and inhaler with tiotropium 921 patients ages 65 99 years with stable COPD. Is this reasonable? Exclusions: last 4 weeks patients had had an exacerbation of COPD or a MI in the last 1 year of congestive cardiac failure (CCF) last 3 years or had a heart arrhythmia on medication. Is this reasonable? Mean screening FEV1 was 39.1% vs. 38.1% of predicted Measured changes were in FEV1, SOB, health status, medication use and adverse effects 81% tiotropium and 72% of placebo patients completed the study 9.6% tiotropium patients stopped due to adverse effects versus 13.7% of placebo.
2.4% tiotropium patients stopped due to lack of efficacy and 7% in placebo There was less wheeze, superior health scores, fewer COPD exacerbations, fewer hospitalisations.
There was no difference in cough or chest tightness.
Side-effects: Tiotropium dry mouth 16% and 2.7% in placebo, other side-effects were at similar rates.
Action effects: morning baseline placebo PEFR: 190 increased to 205 at 1 year and evening PEFR 205 L increased to 210 L. Tiotropium baseline morning PEFR was also 190 L and improved at 1 year to mean 230 L and evening 215 to 240 L.
Bottom line: dry mouth 16% and 30 ml improvement in PEFR.
How does that make us feel about the medication? Is it worth giving? Is it worth pushing the patient if they don't want another inhaler? Do good for the patient: improved PEFR and other scores. Mean improvement 30 ml so modest.
Do no harm to the patient: 16% dry mouth Patients' informed decision-making: Given the evidence, how would the students as doctors present the evidence to a patient? Is the evidence what they would have expected themselves? Justice to the patient and to society: Students and doctors overestimate the benefits of medications at an individual level but a 30 ml gain in PEFR may be helpful to individuals: it also demonstrates how irreversible COPD is.
The students would be signposted to relevant resources by the tutor initially.
Appendix 4. Tutor sheet regarding simvastatin (January 2014) Should patients who have had a MI or angina take simvastatin 40 mg one at night? At present students would be considered to be ‘doing well' if they identified that the UK guideline is to provided patients with a statin after a MI and be able to write this prescription safely, identify that it may cause muscle pain, is liver metabolised and understand that it acts at the liver to reduce cholesterol.
During a short teaching intervention students will be guided to consider the patient perspective: How useful is it to the patient? What are the risks of harm to the patient? Drug use will be considered in terms of Beauchamp and Childress' 4 ethical principles: In order to consider the ethical issues here the students require more than guidelines. They require an evidence base. The evidence bases can found in NICE full guidelines and patient decision aids, also provided by NICE (previously by NPC). There are of course other sources that may be useful and it will be up to students subsequently to find best evidence.
So for the scenario above the evidence would be: Do good for the patient: Reduces second MIs and acts in primary prevention to reduce CHD.
Do no harm to the patient: acts as a competitive inhibitor of HMG CoA reductase, an enzyme involved in cholesterol synthesis especially in the liver so has a number of liver metabolised drug interactions Indications: primary hypercholesterolaemia, prevention of cardiovascular events in patients with diabetes mellitus after coronary risk assessment (CRA), prevention of further atherosclerosis or primary prevention in those with a high CRA (page number not for citation purpose) Jane Wilcock and Janet Strivens Caution eGFR B30 ml/min: reduce dose. Correct hypothyroidism, liver disease, caution in high alcohol intake Monitoring: NICE 2008: liver function tests (LFTs) before starting and within 3 months and at 12 months of starting therapy. ALT above 3  of normal: stop statin. Do not use if increased risk of rhabdomyolysis and patients should report muscle pain.
Acute porphyria is a contraindication as is pregnancy. Patients should use contraception on statins and one month afterwards to prevent possible teratogenicity. Avoid breast feeding.
SEs: myositis, rhabdomyolysis, pancreatitis is rare, GIT disturbance, hepatitis, jaundice, sleep disturbance, rash and others, very rarely pulmonary fibrosis so patients should report a cough to their GP. If myopathy is suspected and creatine kinase is 5  the upper limit of normal or severe symptoms stop therapy.
How do we know it works? How do we measure this? Patients' informed decision-making: Given the evidence, how would the students as doctors present the evidence to a patient? Is the evidence what they would have expected themselves? Randomised trial of cholesterol lowering in 4,444 patients (35
70 years old) with CHD; patients had angina or previous MI and all on lipid-lowering diet with cholesterol 5.5
8 mmol/L. Double-blind randomised trial to simvastatin or placebo, patient were followed up 5.4 years and simvastatin produced a mean 25% reduction in cholesterol and 35% reduction in LDL (1.3 mmol/L reduction) and 8% increase in HDL.
How many patients died and how many had CHD? 12% (256 pts) placebo group died and 8% (182) in the statin group: 4% improvement in CHD life expectancy in the group over 5 years.
189 deaths from CHD in the placebo group (8.5%) and 111 in statin group (5%) and similar non- CHD deaths, about 50 each group (3.5% improvement in survival) Placebo risk of surviving over the years was 88% with a 28% chance having another CHD event but this was reduced to a 19% chance in simvastatin group.
After the trial both groups were offered simvastatin and over 80% of each group continued on simvastatin, initially at 20 mg a day. FU 10.4 years total. 414 pts died on statin and 468 who were originally placebo patients died in 10 years. CHD deaths on statin 238 (11%) and 300 on placebo (13.5%). There were 85 cancers on statin and 100 in placebo group with a similar but slightly increased cancer incidence in placebo group.
75% of LDL cholesterol lowering occurs at 20 mg of simvastatin and 6% extra at 40 mg.
The SEARCH Trial showed no increased benefit of 80 mg simvastatin versus 20 mg simvastatin for mortality and morbidity.
Justice to the patient and to society: Students and doctors overestimate the benefits of medications at an individual level but benefits in society are substantial across groups with CHD.
The students would be signposted to relevant resources by the tutor initially.
Scandinavian simvastatin survival study of 1994 is often called the 4S trial, published in the Lancet (page number not for citation purpose)

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