Prescribing deprescribing for polypharmacy in Aotearoa New Zealand; experiences of a medication review activity in final year medical students on a general practice module

Introduction

Prescribing is a core activity in any medical profession,^1,2 and is a cause of many harms^3–8 if not done with caution. Polypharmacy is particularly harmful due to the increased potential for drug interactions and adverse drug effects, highlighted by the World Health Organization initiative as part of their Global Patient Safety Challenge: Medication Without Harm.⁹ A prescribing cascade frequently occurs when medications are added to counter the adverse effects of others. These additional drugs also have potential for adverse effects. Problematic polypharmacy may be defined as:

the prescribing of multiple medications inappropriately or where the intended benefit of the medication is not realised.⁸

Problematic polypharmacy is a significant global issue for patients, practitioners, and the health sector.^10,11 A 2019 study⁹ found increasing polypharmacy with an increase in age (these findings are summarised in Table 1). People on multiple medications are more likely to be admitted to hospital than someone who is prescribed one to three medicines a day. Furthermore, the frequency of adverse reactions can increase, with 82% of those on seven or more medicines reporting an adverse reaction.¹²

In Aotearoa New Zealand (NZ), 4% of people over the age of 65 years are dispensed 11 or more medications.¹ In general practice, polypharmacy and repeat prescribing without patient review are common and raise concerns over safety issues.^4,13 Medication review for deprescribing is more time consuming for patients and medical practitioners than simply repeating the current list and can be costly for patients in terms of appointment costs.

Training programmes are part of the suggested solution for reducing harms and waste from polypharmacy.¹⁴ Learning to prescribe during medical training at the University of Otago happens across all years of the medical degree.¹⁵ Students do not write prescriptions without supervision, and junior doctors continue supervised prescribing until they have completed their first post-graduate year. Learning ‘good prescribing’,³ reviewing medications and deprescribing are core skills of a prescriber.

Teaching is commonly focused on single organ systems and may not take into consideration the multi-morbid patient. One learning opportunity that most closely reflects the care of a multi-morbid patient is the regular prescribing that occurs in a general practice setting. In the geographical regions where students undertake their general practice module with the University of Otago, the corresponding problematic polypharmacy rates range from 2.6 to 4.5%.¹⁶

This study aimed to explore the value of student and general practitioner (GP) supervisor experiences with the medication review activity undertaken during the general practice module in the final year of medical school. In addition, it looked to ascertain if the volume of work was seen to provide valuable learning and benefit to their future prescribing practice.

Method

The medication review scholarship and assessment activity was introduced into the University of Otago, Wellington campus in 2015 by the Convenor for the general practice module (LG) and the then Undergraduate Director (LMcB). It is a compulsory assessed item that contributes to the final mark for the general practice module and highlights the issues around polypharmacy to students. The assessment is marked by tutors in the Department of Primary Health Care and General Practice (see Supplementary File S1). Tutor marking and written feedback is provided to the student. A small proportion of reviews are returned to the student when further detail is required in the template, often this is because information around social context is omitted or very brief.

In 2018, GP supervisors were presented with some of the completed medication reviews at regional workshops to give them examples of what a high-calibre medication review looked like. These workshops involved a small group activity reflecting on medication reviews that had been marked as resubmit, pass, or excellent. Time was allowed for discussion of how a medication review completed by students might provide value for both patients and GP supervisors. Reflections from the workshops about the time taken to complete a comprehensive medication review was one of the drivers for conducting this study. The Convenors for the programme in 2018 (SM and LG) agreed that a review of experiences from both students and supervisors would provide evidence to support the proposed value of the activity.

Participants comprised final year medical students at the University of Otago, Wellington during their 6-week clinical general practice module (approximately 100 per year) and GP supervisors from general practices. The Primary Health Care and General Practice (PHC&GP) Department contracts with 30–40 practices in the lower North Island each year. Each 6-week module has between 12 and 15 students, with each student placed individually in a practice, with a nominated GP supervisor overseeing their learning experiences. GP supervisors will usually have between 3 and 8 students per year.

In the first few weeks of their general practice module, the students are required to ask their GP supervisor to identify a suitable patient for polypharmacy medication review. Students are expected to see the patient or have sufficient information to conduct a desk-based review and then write up the regular medication chart. Reflection on options for changes to the patient’s current medication regime using evidence-based resources such as Health Pathways (https://3d.communityhealthpathways.org/), The New Zealand Formulary (NZF),¹⁷ Best Practice Advisory Centre¹⁸ and discussion with others eg pharmacist, nurses, and whānau (patient family) is part of the review assignment. On completion of the medication review, the student then discusses the result and their recommendations for change with their GP supervisor. Students write a reflection on this discussion and hand the work in for marking. The medication review is marked independently by a practising GP or GP lecturer within the department and, at the time of this study, these were returned with marker comments to both the student and the GP supervisor. Some students were asked to resubmit their medication review if it did not meet the required standard. This often entailed improved social history, details of prescribing interactions, or a more detailed self-reflection.

Clear instructions for the medication review were available for students on their web-based learning platform (MedMoodle) including a template to provide guidance and consistency (Supplementary File S1).

Between November 2019 and October 2020, all final year medical students undertaking a medication review on their 6-week general practice module were emailed a study survey (Supplementary File S2). A repeat request for completion was sent out a week later. From the end of June 2020, a similar survey (Supplementary File S2) was sent out to the GPs supervising the students during the study period. A second request for completion was also sent out to the supervisors a week later.

Results

Between November 2019 and October 2020, 106 students were eligible for the final year general practice module. Of those, seven students were assigned to an interprofessional education programme and were not required to complete the medication review. Twelve students were affected by COVID-19 lockdown issues and did not complete a general practice module. Eighty-seven students completed a medication review and were eligible to participate in this research. The survey was completed by 48 (55%) students (Fig. 1). Students were placed across 33 practices during that time. Surveys were sent to GP supervisors from June 2020 to October 2020 and 10 (30%) supervisors completed the survey. Fig. 1 shows a flow diagram of student participation.

Fig. 1.

Flow chart of student participants.

Thematic analysis

Five themes were identified in the analysis of qualitative data: value of the medication review; complexity of prescribing; importance of monitoring; value of resources; and supervisor reflections on value to the student.

Discussion

Despite the significant amount of time taken by students and GP supervisors to complete a medication review, this study indicates that students and supervisors consider the activity valuable to themselves, each other, and patients.

Medication reviews have been encouraged and researched^20–24 more widely in recent years due to the increasing burden of polypharmacy across the globe and a desire to ensure medical and pharmacy students have the skills to be able to reflect on, and deal with, a complex array of medications.

Providing a safe environment for students to learn prescribing and deprescribing during their training is essential. Linton and Murdoch-Eaton²⁴ describe 12 tips to facilitate medical student prescribing. Ten of the 12 steps are achieved with the described medication review activity including; start prescribing practice early, include dedicated time, routine access to formularies, prescribing in context, supervised prescribing, focus on high-risk medications, feedback on prescribing, involving the multidisciplinary team, using a range of teaching and learning strategies, embedding prescribing within students’ clinic consultation and practice, and including prescribing in assessments. The medication review activity does not require the student to write prescriptions, however, the general practice module does allow for students to practice prescribing and increases the number of prescriptions they write. Linton and Murdoch-Eaton²⁴ also suggest the use of a student formulary which is not available in NZ.

The allocated time dedicated solely to considering prescribing practice, for both students and GP supervisors, is an unintended benefit of adding a medication review into student general practice placements. GP supervisors reflected that they do not have time to do a formalised medication review themselves, but that the work of the students provided beneficial patient care that they would otherwise be doing out of hours. Supervisors of students often feel that they provide all the learning opportunities. This study highlighted that the GP supervisors themselves learnt new things through the medication review assessment process and that the students were aware of their teaching role.

For students, the medication review is context specific, supervised, complex, and feedback²⁵ driven. It gives an opportunity for the student to provide thoughts and ideas as much as the supervisor – modelling and enabling reflective practice for both participants.^26–28 The review also gives students the opportunity for exposure to the benefits of interprofessional collaboration with pharmacists, although this would be different in the different regions where students were placed. The added value to students was that while learning about a variety of medications they also felt they were contributing to the patient’s health and wellbeing and to their supervisor’s prescribing practice.

The medication review activity was implemented in response to a real-world problem, increasing polypharmacy. This study shows that deliberate structuring of learning activities that reflect on change to clinical practice can be successful and may have more benefit than initially anticipated. It is also hoped that the students will take this experience of managing polypharmacy into their postgraduate years, with improved understanding of the impacts on the patient and the general practice post hospital discharge. The concerns of the authors and comments by GP supervisors at regional workshops around time commitment of this activity appear to be counteracted by the perceived value that the activity provides.

Overall, the results of both surveys reflect the positive value sentiment expressed in previous verbal discussions with both students and GP supervisors.

Conclusion

Medication prescribing and deprescribing are core activities within medical practice. Explicitly learning about deprescribing is important for any prescriber. The results of this study show that a medication review process undertaken by final year medical students, reflecting on polypharmacy, provides significant additional prescribing and deprescribing practice learning and other benefits to students, GP supervisors, and their patients.

Supplementary material

Supplementary material is available online.