An outcome-based approach for teaching prudent antimicrobial prescribing to undergraduate medical students: report of a Working Party of the British Society for Antimicrobial Chemotherapy

Lorraine A. Paterson Davenport1, Peter G. Davey2, Jean S. Ker3,* on behalf of the BSAC Undergraduate Education Working Party{dagger}

1 Clinical Skills Centre, Level 6 Ninewells Hospital and Medical School, Dundee, DD1 9SY; 2 Health Informatics Centre, Kirsty Semple Way, Dundee DD2 4BF; 3 Clinical Skills Centre, Dundee, DD1 9SY, UK


* Corresponding author. Tel: +44-1382-633937; Fax: +44-1382-633950; Email: j.s.ker{at}dundee.ac.uk

Received 13 December 2004; returned 25 February 2005; accepted 9 March 2005


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Antibiotic resistance is on the increase. This is evidenced by the almost daily publication of related articles in both professional journals and the media. The Department of Health and the Scottish Executive have published strategies and action plans that highlight the need for prudent use of antimicrobials. A key strategy in facilitating prudent prescribing is the early introduction of the relevant knowledge concepts and skills into the undergraduate medical curriculum. This reflects the need to ensure graduating doctors are fit for practice (General Medical Council) in accordance with evidence-based antibiotic policies. Outcome-based education has gained increasing credibility as an explicit and systematic approach to developing standards for undergraduate prescribing education. This approach enables performance to be measured accurately. This paper provides an introduction to understanding outcome-based education and how it has been applied in the context of prudent antimicrobial prescribing for undergraduate medical education as defined by an expert working party. In addition, the paper shares how this has then been implemented through the development of a new teaching resource custom designed to assist with teaching the skills of antimicrobial prescribing using an outcome framework. To avoid the increase of antibiotic resistance we advocate that the educational approach to prescribing should be one of achieving shared predetermined outcomes, and that the purpose-designed Appropriate Antimicrobial Prescribing for Tomorrow's Doctors (APT) teaching resource should be referred to and used by students, teachers, assessors, curriculum planners and anyone involved in antimicrobial prescribing.

Keywords: APT , undergraduate education , resistance , prudent prescribing , rational prescribing , appropriate prescribing


    Introducing outcome-based education in prescribing
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Why an outcome-based approach is applicable to learning prudent antibiotic prescribing

The government, healthcare professionals and the public are asking for more transparent and explicit outcomes of our undergraduate medical curriculum. The General Medical Council (GMC) has responded by identifying that certain standards are achieved in professional practice and that medical schools are responsible for ensuring that their graduates possess these skills to practice.1,2 However, with increasing evidence of worldwide antimicrobial resistance3 doctors continue to prescribe antibiotics inappropriately and unnecessarily.47 An outcome-based approach provides an organizational framework to define clearly and express explicitly requirements of the end product.8 The Department of Health9 has recognized the need to improve antibiotic prescribing through education in order to achieve the GMC standards. Medical schools, reinforced by the changing roles of healthcare10,11 and education assessment,8 have been driven to look beyond traditional educational tools to the outcomes of the education programme itself. This movement has led many to adopt the outcome-based approach to both undergraduate1214 and postgraduate education.15,16

An outcome-based approach to antibiotic prescribing can provide the context for some of the more challenging outcomes set out by the GMC to be achieved, namely:1 (i) relationships with patients and colleagues; (ii) professional standards, clinical reasoning and behaviour; and (iii) personal and professional development.

One of the recommendations by the GMC is that: ‘The medical graduate will demonstrate awareness of the moral and ethical responsibilities involved in individual patient care and in the provision of care to populations of patients.’

Antibiotic prescribing can provide a context to address outcomes relating to health promotion for both individual and population health. These conflicts can be recognized within the specifications and use of most local hospital antibiotic policies.17 Prescribing antibiotics then, is an ideal topic to trigger discussion regarding such conflicts, particularly as each doctor must fulfil their role as advocate and adviser by being able to relate explicitly the options available to both the patient and their carer. This will require communication skills, shared decision-making and accountability.18 In addition, the problem of antibiotic resistance provides students and teachers with the opportunity to reflect upon conflicts that arise because of limited healthcare budgets. Further to this, antibiotic resistance can provide an opportunity for focusing on the development of life-long learning skills, a key outcome of professional development. It is therefore a perfect topic to enable learners to build an increasingly complex understanding of antibiotic prescribing problems and how to solve them. Antibiotic resistance varies in different healthcare contexts in relation to both geography and primary and secondary care settings, and so provides an excellent opportunity for students to learn how to access the information that they need to keep up to date with and how to use this information to make appropriate changes in their practice. Solving the problem of antibiotic resistance requires the application of the full range of scientific knowledge that underpins medicine through biomedical, clinical and health services, and epidemiological research. It is therefore a topic that will be of immediate interest to students at the start of their undergraduate training. This approach to medical education can support both organizational and system change,19 which can apply to prudent antibiotic prescribing.

What is outcome-based education?

It is important to understand that outcome-based education is about providing unambiguous statements of learning intent. These explicit statements serve to ensure that the educational processes are designed to achieve the required outcomes. Education within such a framework permits flexibility of delivery, allowing individual institutions to generate the methods by which the outcomes are achieved, without requiring rigid adherence to a set of standard teaching methods. By definition, all medical schools produce outcomes, but an outcome-based education approach enables this to be achieved in a systematic and explicit way. Outcome-based education reorients medical education from a process to a product approach where the end product is principally related to the required and predetermined outcomes. What is more, this approach can, by the explicit declaration of expected outcomes, identify the potential process by which the outcomes can be achieved.11,19 In other words the very act of defining something can elucidate the parameters and framework with which to achieve it.

What are the values of learning outcomes?

Learning outcomes are the clear results we wish to achieve. They are not beliefs, attitudes or mind-states. They are statements of actions and performances that represent learner competence and the tangible application of what the learners can actually do. They provide an end product check-list of clearly defined broad performance capabilities, which enable the student and teacher to orient and focus the educational experiences.

An outcome-based approach to education has other benefits too. Advantages include the ability to address controversial issues of curriculum content and to provide a focus for the relationship between curriculum design and the practice of medicine.20 An outcome-based approach also makes explicit the continuity of education for each phase of education19 from undergraduate through postgraduate and on to continuing professional development. It provides a robust curriculum framework that is jargon free. This transparency of the curriculum can encourage self-directed learning by the student. It also can highlight any shortcomings of the current curriculum content.21 This approach also emphasizes accountability and quality assurance in relation to the product whilst permitting flexibility in the curriculum delivery. Learning outcomes establish a direction and focus for assessment strategies and curriculum evaluation.19 Learning outcomes are ethically sound22 and, because of their explicit nature, readily accepted by most teachers as a support for their teaching.23 They provide clear guidance for the planning and development of the teaching process, including the design and organization of their materials, and hence selection of the most appropriate teaching methods, as well as providing a measure for quality assurance. Learning outcomes can also ensure that students who require remediation receive it. Explicit learning outcomes give students a clear understanding of what is expected of them, enabling them to learn more effectively.

Debating the concerns about outcome-based education

For Spady,24 the values of outcome-based educational systems are overwhelming. It makes clear what your teaching should accomplish, and modifies it accordingly.20 Outcome-based education is not a trend,25 but it has its critics.24 Some find it difficult to define,20 that it requires extensive support structures,26,27 that there is little research evidence behind it28 and that it is limited by a weak instructional model recommending mastery, individualized strategy and promotion-based achievement.25 Furthermore, others claim that outcome-based education promotes egalitarian dumbing-down, limiting creativity, imposes rigidity on planners, inappropriately addresses attitudes and imposes excessive demands on teachers.29 Others, although supportive of outcome-based education, believe that its success is not as a curriculum tool but rather as a training and instruction design tool where the educational philosophy is as an induction into knowledge.30

Table 1 highlights the positive features of outcome-based education and some of the key criticisms as they relate to aspects of the educational process.


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Table 1. Key learning points: positive features of outcome-based education, common criticisms and comments

 
Learning outcomes can assist teachers in planning their content and thereby providing formats for their teaching materials, informing their approaches and ensuring that appropriate assessment strategies are employed. What is required is a fundamental shift in emphasis, with institutes providing quality staff development, including aide support, release/preparation time and possibly smaller classes, which will result in positive change.

Using outcomes and the three-circle model

Learning-based outcomes can be presented in a variety of ways. Brown University, USA, opted for the format of a nine-item ability list,12 as did the English National Board of Nursing, Midwifery and Health Visiting.19 The Association of American Medical Colleges14 developed a set of goals and designed a guidebook to permit individual schools to establish objectives according to the defined attributes for their own curricula. Furthermore, the American Board of Internal Medicine,31 the Royal College of Physicians and Surgeons of Canada,32 and the Accreditation Council for Graduate Medical Education33 have stipulated sets of learning outcomes for postgraduate and continuing education. In the UK, the University of Birmingham Medical School has successfully implemented an outcome-based learning (and electronic) undergraduate curriculum.13 In Dundee, the Medical School has developed a three-circle, 12-outcome model that defines the learning outcomes for undergraduate medicine,19 and offers a tool to implement the outcome-based approach. The three-circle model consists of three levels of detail (Figure 1).



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Figure 1. The three-circle model: the essential elements.

 
The first level of the model identifies the essential elements of the competent and reflective practitioner: (i) what the doctor is able to do; (ii) how the doctor approaches their practice; and (iii) the doctor as a professional.

The second level identifies the 12 key domains of the essential learning outcomes, nested within the first level: (i) clinical skills; (ii) practical procedures; (iii) patient investigation; (iv) patient management; (v) health promotion and disease prevention; (vi) communication; (vii) appropriate information handling skills; (viii) understanding of basic and clinical sciences and underlying principles; (ix) appropriate attitudes, ethical understanding and legal responsibilities; (x) appropriate decision-making skills, and clinical reasoning and judgement; (xi) role of the doctor within the health service; and (xii) personal development.

Finally, the third level identifies the details of these key learning outcome domains. The three-circle model has been accepted and endorsed by all Scottish medical schools and is currently under varying degrees of implementation and adaptation in their undergraduate curricula. In addition, the model has been adopted for the pre-registration house officer year in Scotland,15 while the General Dental Council has adopted the model in their revised document The First Five Years.34 In addition to this, an adapted version for dentistry has been applied in orthodontics by the Standards Advisory Committee.


    The process of employing learning outcomes in prescribing
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In a society where the rate of inappropriate prescribing and use of antibiotics, and the subsequent increase in antimicrobial resistance, is evident,46 the need to address this issue in education is a priority. The Appropriate Antimicrobial Prescribing for Tomorrow's Doctors (APT) project was established to address this need at undergraduate level. The APT Working Party was formed and included representatives from each of the five Scottish medical schools, together with members of the BSAC Undergraduate Working Party (representing Belfast, Southampton, Birmingham, Nottingham, and Coventry and Warwick). The BSAC Working Party aim was to determine the learning outcomes for undergraduate prudent antimicrobial prescribing, while the APT Working Party aimed to operationalize them within the framework of the three-circle, 12-outcome model.

Defining the outcomes for prudent prescribing

The Working Party first agreed a set of key questions that a prudent prescriber should answer before initiating antimicrobial therapy. The BSAC Working Party determined the following five questions that a doctor should address in order to reach a decision about antibiotic prescribing:

  1. Should an antibiotic be prescribed? (Outcomes 4, 8, 9 and 10)
    1. What does the patient want?
    2. How could this problem be managed without prescribing an antibiotic?
    3. How severe is the infection and what are the potential clinical outcomes?
    4. Where is the evidence to support antibiotic prescribing or alternative strategies?

  2. Which antibiotic should be prescribed? (Outcomes 2, 4, 5, 8, 9 and 10)
    1. What is the most prudent first line choice?
    2. What are the contraindications to the first choice drug(s) and what alternatives should be used?
    3. What dose, by what route and for how long?

  3. What treatment is required in addition to antimicrobial chemotherapy? (Outcome 4)
  4. How will response to treatment be assessed? (Outcomes 8, 9 and 10)
    1. How do you know if things are going wrong?
    2. What do you do if response is not satisfactory?
    3. How do you know when to stop treatment?

  5. How will decisions be communicated? (Outcomes 6 and 7)
    1. What data need to be recorded in order to support each decision?
    2. What information does the patient need?
    3. Who else needs to know?

Using these questions the Working Party employed a consensus process to agree detailed learning outcomes under each of the 12 domains of the three-circle model.12 First, a list of generic outcomes was agreed, and then members worked in pairs to define detailed learning outcomes. To ensure the relevancy of each learning outcome each pair performed the process for specific clinical problems. To ensure a consensus was achieved regarding these definitions or detailed learning outcomes, each pair's work was then subjected to a series of rigorous review processes by all the Working Party members. The outcomes for undergraduate prudent antimicrobial prescribing can be viewed in Table 2. These outcomes provided the trigger for developing a supportive learning resource that could be used in different learning situations including for self-learning, self-assessment, peer review, small group discussion or formal assessment.


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Table 2. The 12 learning outcome domains for undergraduate education of prudent antibiotic prescribing

 
The development of the APT teaching resource using an outcome-based approach

As patients present with problems or concerns, not diagnoses, students can develop their skills in problem-solving by working through common clinical scenarios. The APT project used the learning outcomes to develop a coordinated student-centred teaching resource for prudent antimicrobial prescribing based on clinical scenarios (vignettes). This resource, which is currently password protected, is being piloted for 6 months by several institutions before becoming more widely available. The techniques employed in the resource creation advocated a collaborative model of resource development based on a loop of expert and user consensus and feedback. The very ‘product’ nature of outcome-based education not only supports this approach but also provided the standard framework for declaring the overt outcomes (to be achieved), ultimately facilitating communication and understanding between the experts in the Working Party.

By employing an outcome-based education approach and focusing on gathering consensus opinions and expert needs, the members of the APT project have created a resource template for teaching prudent prescribing. The resource is readily useable, patient-based and consists of several reuseable inter-related components: (i) standardized vignettes covering the 12 learning outcome domains; (ii) a reflective patient record book, including a personal antibiotic formulary; (iii) discussion session guidelines; (iv) prescribing exercises; and (v) a support resource pack.

How the APT materials are used within individual educational institutes will depend on many issues, including the organization of the curricular programme, the available teaching resources, and the level of experience of students, as well as timetabling issues. With this in mind the materials have been designed for flexible use within a recommended fundamental educational structure of student preparation and reinforcement using the outcome-based approach.


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No single educational approach is perfect, and many are clouded with contradictions, inferences, indecision and masked agendas. Outcome-based education advocates explicitly defined and detailed requirements to ensure medical graduates are fit to practice, and in this case fit to prescribe antibiotics to minimize resistance and maximize their effective and efficient use. Outcome-based education attempts to remove the guesswork, to be open and explicit about what is required, creating a more joined-up approach. Although an outcome approach will always have its critics and areas for concern, when employed together with consideration and insight it is a powerful tool for clarity, planning, assessment and evaluation of any course, whilst also providing information to support both the students and the tutor in their quest for educational accomplishment.

The detailed learning outcomes identified here are grounded in the views of the Expert Working Party, and aim to achieve an improved educational focus at medical undergraduate level on antimicrobial prescribing and hence provide a teaching tool to address the critical issue of inappropriate prescribing and increased antibiotic resistance. The APT teaching resource advocates an outcome-based approach and, following piloting, will be available online for everyone to use.


    Footnotes
 
{dagger} Members of the BSAC Undergraduate Education Working Party are listed in the Acknowledgements. Back


    Acknowledgements
 
Written on behalf of the BSAC Undergraduate Education Working Party members: 2000–2002: Roger Finch, Ronald Harden, Bill Holmes, Jane Leese, Alasdair MacGowan, Bob Masterton, Marina Morgan; from 2002: Roger Finch, Paul Little, Bob Masterton, Marina Morgan, Ian McKay, Cliodna McNulty, Keith Struthers, Hugh Webb, Roland Koerner, Stephanie Dancer.


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