Assessment of Bangladeshi Interns ' Knowledge of Pharmacology and Therapeutics for Prescribing

Md. Zakirul Islam, Md. Faizur Rahman, Abu Syed Md Mossaddek, Rini Juliet Rozario, AF Md. Hassan Iftekhar, Shakil Akhter, Iffat Jahan, Asadul Mazid Helali, Wan Putri Elena Wan Dali, Salwani Ismail, Nor Iza A Rahman, Mainul Haque Department of Pharmacology & Therapeutics, Eastern Medical College, Comilla, Bangladesh. 2 Department of Pharmacology & Therapeutics, Uttara Adhunik Medical College, Dhaka, Bangladesh. Department of Pharmacology & Therapeutics, Shaheed Monsur Ali Medical College, Dhaka, Bangladesh. Department of Pharmacology & Therapeutics, Central Medical College, Comilla, Bangladesh. 5 Department of Pharmacology & Therapeutics, Bangladesh Medical College, Dhaka, Bangladesh. 6 Department of Physiology, Anwar Khan Modern Medical College, Dhaka, Bangladesh. 7 Department of Pharmacology & Therapeutics, Gonoshasthya Samajvittik Medical College & Hospital, Dhaka, Bangladesh. 8 Faculty of Medicine and Health Sciences (FPSK), Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia.


INTRODUCTION
'Pharmacology is the backbone of Clinical Medicine (Chaurasia, 2013).Prescribing correct therapy is the essential part of physicians and therefore, adequate knowledge on drugs' efficacy, safety, cost, and convenience is important (Mohan et al., 2012).Lessons in Pharmacology provide and enrich medical students' knowledge and skill about different drugs and their utility in various diseases (Upadhyaya et al., 2012).Fresh medical graduates very often need to prescribe many times a day.
. (O'Shaughnessy, 2010).Every medical doctor needs to develop the skill to 'select' the right medicine for any disease from a very wide range of therapeutic choices (Upadhyaya et al., 2012).Pharmacology should be taught aiming to produce future rational prescriber.Therefore, rational use of medicine will ensure and the most important and vital proficiency of doctors will be achieved (Rangachari, 1997;Akat et al., 2012;Theodorou et al., 2009).It is over decade back General Medical Council of UK made a rule that every medical doctor must have the skill to prescribe safe and effective drugs (GMC, 2003).Even then there is rising apprehension in the countries of both side of Atlantic that 'medical error' is harming lot patient's treatment (Department of Health, 2000;Institute of Medicine, 2000).Erroneous choice of drug is one of the top medical errors and as high as 2% of all hospital admission in USA is due to 'medication errors' with majority of paediatric patients (Leape et al., 1999;Barber and Dean, 1998;Kaushal et al., 2001;Barber et al., 2003).In the United States, medical error results in 44,00098,000 unnecessary deaths each year and 1,000,000 excess injuries' (Weingart et al., 2000).Again these mistakes and faults are mostly due to poor prescribing skill (Leape et al., 1995;Bates et al., 1995).Inadequate prescribing knowledge and skill in the both developed and developing countries are also reported in numerous published articles (Palmer et al., 2001;Odusanya, 2004;Oshikoya and Chukwura, 2006;Abebayo and Hussain, 2010;Otoom et al., 2010;Chima et al., 2012;Goswami et al., 2013;Gawde et al., 2013).
In spite of lot failure to ensure safe and rational prescribing, the traditional teaching of pharmacology still continues in many countries of the world including Bangladesh (Michel et al., 2002;Walley et al., 1994;CME, 2002;BMDC, 2012).Medical curriculum is strictly controlled by government of Bangladesh (GOB) and it is unique for every medical school of the country (CME, 2002;BMDC, 2012).Pharmacology, last almost over a decade, was taught for two years in the phase II of MBBS programme as a part of second professional exanimation (CME, 2002).GOB has launched a new updated version of curriculum and it is implemented from 2014.Present plan of teaching pharmacology and therapeutic will be taught for one year in phase III (BMDC, 2012).There are no other pharmacology class in rest of the curriculum plan (BMDC, 2012).In earlier curriculum, there were three professional exams but now it will be four and pharmacology will be in phase III after one year of formal teaching (BMDC, 2012;Haque et al., 2012).There are multiple reports published from a number of countries that medical students have much difficulty in prescribing correct drugs (Dehghani et al., 2008;Oshikoya et al., 2009;Garbutt et al., 2005;Oshikoya et al., 2007;Dornan et al., 2009;Heaton et al., 2008;Wall et al., 2006).Traditional didactic teaching of pharmacology often creates enormous pressure to learn very high amount of information though memorising (Michel et al., 2002;Walley et al., 1994;Oshikoya et al., 2007;Dean et al., 2002;Queneau et al., 1998).Therefore in real life situation, the students suffer from under developed logical and scientific approach of prescribing, eventually leading to poor prescribing quality (Walley et al., 1994;Oshikoya et al., 2008;Dean et al., 2002;Ryan et al., 2014).Obviously poor prescribing does not ensure benefit and comfort of patient rather increases morbidity and mortality (Motamed et al., 2006).Pharmacology is basic science and like many other basic subject some time both students and teachers feel it is very 'dry' in describing and interpreting concept (Bradley et al., 2006).At many occasion these concept are quite complicated in early years of medical school.Henceforth, modern countries and in some neighbouring countries of Bangladesh has adopted newer more updated teaching methods with more clinical orientation and therapeutics and integration of curriculum to ensure more interest and effective teaching and learning (Michel et al., 2002;Flockhart et al., 2002;Orme et al., 2002;Vollebregt et al., 2006;MCI, 1997;Shankar et al., 2005;Aronson et al., 2006).These methods have significantly changed the situation of drug use.Therefore, ensures more rational use of medicine and communities are getting more safe and effective drugs (Michel et al., 2002;Flockhart et al., 2002;Orme et al., 2002;Vollebregt et al., 2006;MCI, 1997;Shankar et al., 2005;Aronson et al., 2006;Shankar et al., 2003;Richir et al., 2008).WHO also promoting as core intervention area for rational use of medicine (WHO, 2002).Henceforth, renowned British group of scientist also reported that pharmacology training should be continued and enhanced in early years of medical doctors (Walley et al., 1994).
Bangladesh introduced the National Drug Policy back in 1982 with an intention of availability of essential drugs at cheaper price and to promote rational use of medicine (RUM) (Rahman et al., 1998).Even then this highly appreciated drug policy cannot ensure much improvement in RUM probably due to some errors in the said policy (Rahman et al., 1998).Irrational use of drugs also been reported for private practitioners and in primary health care centres (Rahman et al., 2009;Gynon et al., 1994) with rare exceptions in teaching hospital like Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University Hospital (BSMMUH) (Karim and Haque, 1995;Rahman et al., 2007).The current survey has carried out to ascertain the level of knowledge of pharmacology among the Interns of Bangladesh in six different medical schools.The findings of our survey will provide us better understanding of current status of pharmacology understanding among freshly graduated physicians in Bangladesh.

MATERIALS AND METHODS
This was a cross-sectional study conducted on Interns of Bangladesh.The study population was all (191) of six medical schools of Bangladesh.Medical schools are Bangladesh Medical College (BMC), Central Medical College (CMC), Comilla Medical College (CoMC), Eastern Medical College (EMC), Shaheed Monsoor Ali Medical College (SMAMC), Uttara Adhunik Medical College (UAMC).CoMC is state owned and rest five medical college is privately established.Bangladesh has unique curriculum for both government and private medical school (CMC, 2002;BMDC, 2012).
These medical colleges are affiliated with public University.In Bangladesh by law all medical colleges must be affiliated with public University.Convenient sampling technique was used to select the sample.The period of study was August to November 2013.Data was collected using a validated instrument (Oshikoya et al., 2009) which is developed on the basis of another study conducted in Scotland (Tobaiqy et al., 2007).Questionnaire then was modified for Bangladeshi context.Thus it was pretested and again validated.This questionnaire has five sections.Section I is demography; section II is undergraduate pharmacology and therapeutics teaching; section III is internship training; section IV is knowledge of adverse drug reactions (ADRs); and section V is drug information references and how to improve undergraduate pharmacology and therapeutics teaching.The data was then compiled and analysed using SPSS version-16.
Over 97% (187) of current study population agreed that pharmacology and therapeutics were taught in their undergraduate MBBS course.Majority of the participants of the study rated that knowledge of pharmacology at graduation level is from average to excellent.Out of these 191 participants 81 (42%), 77 (40%), 15 (8%), 13 (7%), and 5 (3%) rated pharmacology knowledge is good, average, poor, excellent, and very poor respectively.Again our 80% (152) intern population feel that undergraduate training has prepared them to prescribe safely.Only 20% (39) interns have negative opinion.Same population group opted only 65% (125) that undergraduate training prepared them to prescribe rationally and rest 35% (66) interns say no.Interns identified few other factors that affect to prescribe rationally.Those are: drug-drug interactions, less confidence, newer drug selection, P drug selection, paediatric doses, patient's financial status, patient's genetic factors, restriction to prescribe, and senior guided prescription.Very interestingly 43% (83) feel that they have some specific problems with prescribing during internship and rest 57% (108) encountered no such problem.Specific problems of prescribing during internship are: drugs used in COPD, bronchial asthma, hypertension, diabetes mellitus; less chance of independent prescribing; less correlation between knowledge and clinical practice; paediatric doses; pharmaceutical insistence on prescribing; rational use of analgesics and antibiotics; varieties of brand name; varieties of clinical use of drugs.
Ninety-four percent (179) of study population interns do understand the term adverse drug reactions (ADRs) but unfortunately 12 (6%) interns do not recognise the word.Again 117 (61%) of interns have already seen cases of ADRs but 39% (74) did not seen any such case in their internship period.Among observed ADRs cases 31% (59), 16% (31), and 14% (28) need or suffered from short hospitalisation, prolonged hospitalisation, and morbidity respectively.Our respondent reported most likely causes of ADRs are 68 (36%), 19 (10%), 22 (11%), and 8 (4%) due to drug-drug reactions, medication error, idiosyncratic reactions and others (overdose) respectively.Interns agreed [71% (135)] that ADRs are avoidable.Although 29% (56) think ADRs are unavoidable.Again majority (74%, 135) of interns' opinion is ADRs are predicable but 26% (49) interns consider that it is not.Again 72% (138) interns agreed that a good knowledge of undergraduate pharmacology and therapeutics teaching would prevent ADRs.On other hand 28% (53) intern opinion that undergraduate pharmacology has no influence to prevent ADRs.Fifty-nine percent (113) interns agreed that they have reported ADRs but rest 41% (78) did not reported.Interns reported about ADRs to Director, Drug administration (12, 6%), ADRs monitoring Committee of the Hospital (10, 5%), and Head of Department (91, 48%).Eighty one percent (154) interns agreed that they were taught how to prevent ADRs occurrence in undergraduate pharmacology and therapeutics course.In contrary only 19% (37) have opted that they did not learn to prevent ADRs in pharmacology and therapeutics coursework.Sixty-two percent (119) of interns said that they go for proper discussion and updated their knowledge and awareness about ADRs after they started their internship but rest 38% (72) viewed that they have no formal discussion about harmful effect of drugs.According to the intern, factors that influence one drug to prescribe come in following way, safety (150, 78%) is first, efficacy (95, 50%) is second, cost (72, 38%) is third, and others (2, 1%) is fourth.
Majority (147, 77%) of the respondents demanded that they routinely consult reference source for drug information.

DISCUSSION AND CONCLUSIONS
The main mass of the study population agreed that their knowledge of pharmacology and therapeutics is from average (40%), good (42%), and excellent (7%) which is quite similar with findings of Nigeria (Oshikoya et al., 2009).Although there were multiple report of irrational prescribing (Rahman et al., 1998;Ivy et al., 1998;Baqui et al., 1998;Rahman et al., 1999;Momen et al., 1999;Das and Rahman, 2010).It is possible as because pharmacology course in MBBS programme in Bangladesh only taught mainly theoretical pharmacology and almost no practical prescribing skill is taught in MBBS course (CME, 2002;Heaton et al., 2008;Oshikoya and Bello, 2008;Tobaiqy et al., 2007;Das and Rahman, 2010).Furthermore same population group (Table 2) identified a long list of medicines for paediatric, geriatric, pregnancy and lactation, and also patient with impaired with renal and liver function that they are reluctant to prescribe.This also similarly not properly taught in their course curriculum as like in many other countries (CME, 2002;Parmar and Jadav, 2006;Oshikoya et al., 2008b).Unfortunately newly launched curriculum for the whole nation does not have such programme for the development of prescribing skill (BMDC, 2012).This is worth to mention that Bangladesh has a unique curriculum for whole country irrespective of state control medical school or private or for different universities (CME, 2002;BMDC, 2012).Curriculum solely dependent on instructive teaching methodology student need to memorise more than to evaluate critically and develop understanding.Therefore it is very often difficult to replicate and utilise their knowledge in clinical settings (Oshikoya et al., 2009).Interns' of study population more than half (61%) observed ADRs.These ADRs are mainly due to drug-drug interactions, medication errors, and idiosyncratic reactions.In consequence Bangladeshi patients need to stay longer time in hospital and increased morbidity.No study respondents have observed death due to ADRs.This finding has much similarity with other studies both unindustrialized and modern countries (Oshikoya et al., 2009;Levy et al., 1980;Mannesse et al., 2000;Mjörndal et al., 2002;McDonnell and Jacobs, 2002;Pirmohamed et al., 2004;Patel et al., 2007;Oshikoya et al., 2007;Thiesen et al., 2013).
"The flood of new drugs in recent years has provided many dramatic improvements in therapy, but it has also created an equal number of problems.Not the least of these is the 'therapeutic jungle', the term used to refer to the combination of the overwhelming number of drugs, the confusion over nomenclature and the associated uncertainty of the status of many of these drugs" (Gilman et al., 1985).The situation also exist in Bangladesh as there are more than 1100 generics and every year 50 to 60 new drug molecule is entering country's drug market (Salam et al., 2013).Thus 'drug explosion' also exist in least developed country like Bangladesh (McGettigan et al., 2001).Even though new options open many therapeutic advantages for patients in many areas where there were no treatment options available in earlier period, but it are reported that this 'therapeutic jungle' actually does not promote rational drug use (McGettigan et al., 2001).There are multiple reports of irrational prescribing due to such opulent range of therapeutic options (Hogerzeil, 1995;Donoghue and Tylee, 1996;Laumann and Bjornson, 1998;Nyquist et al., 1998;Liu et al., 1998;Strauss et al., 1999).Majorities (77%) of respondents are checking references before prescribing which is extremely good habit and promote rational prescribing.This is may be due to that they are working in teaching hospital and under proper supervision with log book.This finding is also at par with other studies (Oshikoya et al., 2009;Oshikoya, 2006).It is reported "Pharmaceutical manufacturers spend vast sums of money on promotion, including sales representatives, samples, advertisements in broadcast and print media, and sponsorship of educational events and conferences.In the USA alone, almost US$21 billion was spent on promotion in 2002.Developing countries sales representatives are frequently the only source of drug information" (Norris et al., 2005).The recent figure of expenditure regarding promotion in alone in USA is much higher and it is $ 27 billion (Cegedim Strategic Data, 2012).There are multiple reports even from neighboring countries that pharmaceutical companies' influences medical doctors to promote their products even they adopt unethical means also (Akandel and Aderibigbe, 2007;Rohra et al., 2007;Oshikoya et al., 2011;Narendran and Narendranathan, 2013;Goyal and Pareek, 2013).But our study found only 9% of the interns' uses pharmaceutical promotional materials for drug information, which is a very highly praiseworthy attitude in Bangladesh.Although it is possible as because they are interns thus reasonably highly supervised in a teaching hospital and there is another cause that as because the research were conducted by their teachers thus they were cautious to answer they use frequently pharmaceutical promotional materials for drug information.
Eighty-three percent of the study respondents feel retrospectively that Pharmacology and Therapeutics course should be improved to ensure rational prescribing.They have suggested some means for improvement and also identified a number of area.This outcome is correspondingly quite comparable with a number of studies done in European countries and Canada (Heaton et al., 2008;Tobaiqy et al., 2007;Han and Maxwell, 2006;Franklin et al., 2007;Fijn et al., 2002, Qayyum et al., 2012).Although majority of the interns' demanded they are competent enough to prescribe safely (80%) and rationally (65%).Furthermore same study population has identified at least 12 areas they have specific problems which include chronic obstructive pulmonary disease, bronchial asthma, hypertension, diabetes mellitus, rational use of analgesics and antibiotics, paediatric doses, duration of drugs.They also made a long list of drugs they are quite reluctant to prescribe.Therefore, it is unlikely that Bangladeshi interns have developed enough skill of good prescribing for their rest of the life within one year of training in hospital placement.
Despite limitation of this cross sectional study, this study identified that pharmacology and therapeutics course curriculum is not enough to produce safe prescribers.Therefore, there is an urgent need of modifying Pharmacology course curriculum.The concerned medical educationist must be aware of the situation and start thinking of a way to teach medical students on how to improve prescribing quality in Bangladesh, and initiate a welldesigned prospective study to identify more preciously the problems of prescribing.Such understanding and implementation will yield better choice of drugs for the consumers of Bangladesh.

Table 1 :
List of drugs that interns would comfortably prescribe without supervision.

Table 2 :
List of drugs that interns would reluctantly prescribe to children, elderly, pregnant women or people with renal/ liver impairment.