Promoting more conservative prescribing.

ALTHOUGH MEDICAL AND PHARMACY CURRICULA and journals are rich with information about drugs and treatment of specific diseases, there is a paucity of education on ways to become effective lifetime prescribers. Two recent reports from the Association of American Medical Colleges (AAMC) lamented the current state of pharmacology teaching and the disturbing extent of pharmaceutical industry influence at all stages of medical education. Given the welldocumented prevalence of medication-related harm and inappropriate prescribing, such educational reform is necessary but not sufficient to ensure that patients are optimally treated. Beyond improved training in pharmacology and minimization of unbalanced industrysponsored education, trainees need guiding principles to inform their thinking about pharmacotherapy to help them become more careful, cautious, evidence-based prescribers. In this Commentary, we offer 25 such principles (BOX), making no claims that they represent the definitive or comprehensive antidote to the many factors contributing to suboptimal prescribing. However, based on our experience educating physicians, pharmacists, and medical students, we believe these lessons are fundamental for teaching clinicians how to develop excellent prescribing skills, yet such fundamentals are absent or underemphasized in current medical and pharmacy education. The AAMC report emphasized expanded teaching about “factors that make each patient unique,” pharmacology and pharmacokinetics, optimal dosing, prescribing regulations, drug interactions and adverse reactions, and use of drug compendia and informational resources. However, prescribers also need to be taught a set of skills and attitudes that will help them approach claims for drugs, especially new drugs, more critically. Although the AAMC document discusses the need for a number of patient monitoring and communication functions embodied in these conservative prescribing principles, without a more cautious and, frankly, more skeptical approach to using drugs, prescribers will lack the will and the skills to resist ubiquitous promotional messages encouraging them to reach for newer and often more expensive medications. Such skepticism needs to be grounded in historical and current lessons that offer reasons for precaution. Lessons from iatrogenic events related to agents such as thalidomide, phen-fen, or rofecoxib (Vioxx); recognition that new medications are tested in limited numbers of patients with few comorbidities, typically for a relatively short time; and disquieting revelations that promotional activities distort what prescribers learn about drugs are lessons worth learning and incorporating into prescribing decision making. Although the attitudes and behaviors recommended in our principles should not be terribly controversial, taken together they represent a departure from current practice. If prescribers routinely heeded these principles, many patients could be spared the risk or expense of needless or harmful drug therapy.