|Year : 2010 | Volume
| Issue : 2 | Page : 132-136
Current scenario of attitude and knowledge of physicians about rational prescription: A novel cross-sectional study
Rajiv Mahajan1, Navyug R Singh2, Jaswinder Singh3, Alok Dixit4, Amit Jain5, Ashwani Gupta6
1 Department of Pharmacology, Adesh Institute of Medical Sciences and Research, Bathinda, India
2 Department of Pharmacology, Government Medical College, Amritsar, India
3 Department of Pharmacology, Sri Guru Ramdas Institute of Medical Sciences & Research, Amritsar, India
4 Department of Pharmacology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, India
5 Department of Pharmacology, Guru Gobind Singh Medical College, Faridkot, India
6 Department of Pharmacology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Patiala, India
|Date of Submission||10-Mar-2010|
|Date of Decision||06-Apr-2010|
|Date of Acceptance||15-May-2010|
|Date of Web Publication||2-Aug-2010|
Department of Pharmacology, Adesh Institute of Medical Sciences and Research, Bathinda
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: In the last 30 years concepts in pharmacology have moved from Essential Medicines (EM) to P-drugs via the Rational Use of Medicines (RUM), but no structured study has evaluated the level of understanding among the working clinicians about these concepts. Aim: The present study was designed to assess the attitude and knowledge of clinical practitioners about the concepts of RUM, EM, P-drugs, and sources of drug-information, across North India. Materials and Methods: A cross-sectional study was carried out in and around the teaching hospitals attached to Medical Colleges, enrolling 504 clinicians from six centers across North India to fill-up a questionnaire containing 25 questions. Statistical Analysis: The results were compiled using percentages and averages. Univariate analysis, which explores each variable in a data set separately, was carried out by using the Fisher's exact test. Results: Only one-fourth of the participants claimed that they always prescribed Essential Medicine; no one could correctly count the number of drugs / drug combinations in the Indian Essential Drug list; only 15.1% of the clinicians wrote the generic names of drugs on the prescription slip; about one-third of clinicians were not fully aware about the adverse effects, drug interactions, and contraindications of the drugs they prescribed; about 83% of physicians admitted to relying on information from Medical Representatives and an interest in research activities seemed to be lost. Conclusion: Results show a sorry state of affairs among clinicians, as far as the level of understanding about EM, P-drugs, and RUM is concerned, and it points toward arranging more continuing medical education (CME) for clinicians with regard to these concepts.
Keywords: Essential medicines, evidence-based medicine, P-drugs, physicians, rational use of medicines
|How to cite this article:|
Mahajan R, Singh NR, Singh J, Dixit A, Jain A, Gupta A. Current scenario of attitude and knowledge of physicians about rational prescription: A novel cross-sectional study. J Pharm Bioall Sci 2010;2:132-6
|How to cite this URL:|
Mahajan R, Singh NR, Singh J, Dixit A, Jain A, Gupta A. Current scenario of attitude and knowledge of physicians about rational prescription: A novel cross-sectional study. J Pharm Bioall Sci [serial online] 2010 [cited 2020 Feb 22];2:132-6. Available from: http://www.jpbsonline.org/text.asp?2010/2/2/132/67008
The concept of Essential Medicines (EM) was launched in 1977, with the publication of the first Model List of Essential Medicines by the World Health Organization (WHO), in response to a request from the World Health Assembly. Since then, this Model List has been revised and updated continuously.  In the last 30 years, we have moved from EM to Personal drugs (P-drugs) via the Rational use of Medicine (RUM) and Evidence Based Medicine (EBM).
The selection of EM is only one step toward the improvement of the quality of healthcare; the selection needs to be followed by its appropriate use. Each individual should receive the right medicine, in an adequate dose for an adequate duration, with appropriate information and follow-up treatment, at an affordable cost. This forms the corner-stone of the concept of Rational Use of Medicine. 
To boost the cause of RUM, the P-drug concept was specified in the late nineties. The idea was to make physicians familiar with few Personal drugs chosen from national essential drug list, based on efficacy, safety, suitability, and cost, with regard to the population they cater to.  The backbone of all these concepts is evidence-based medicine (EBM), which means making decisions about the care of individual patients by integrating individual clinical expertise with the explicit and judicious use of the best current evidence, available from systematic research. 
The World Health Organization (WHO) has developed recommendations for twelve core national policies and structures that are needed to promote RUM.  The main areas where developing countries are still lagging behind are, problem-based pharmacotherapy training in the undergraduate curriculum, in-service CME as a licensure requirement, independent information on medicines, and avoidance of perverse financial incentives.
Problem-based pharmacotherapy training is not a part of undergraduate training in most of the developing countries, although, a debate has started now, to include it in undergraduate training. , It is being tested in some medical schools, , but the professionals who are already in practice hardly know these concepts. Moreover, in-service CME is lacking in the developing countries; and if at all CME is conducted, it is mostly sponsored by drug houses having their own market interests. More importantly, physicians rely heavily on drug information provided by medical representatives. Dependence on independent, peer-reviewed sources is negligible. This can lead to irrational prescription patterns.
In the light of the aforementioned discussion, the present study was carried out to assess the attitude, awareness, and knowledge of clinical practitioners with regard to the concepts of RUM, EM, P-drugs, and sources of drug-information, across North India.
| Materials and Methods|| |
In February 2010, a cross-sectional study was conducted simultaneously in and around six referral teaching hospitals attached to Medical Colleges across North India, after taking approval from the Institutional Ethical Committee. After taking the informed written consent, clinicians from different disciplines working in these Medical Colleges and in the vicinity of these Medical Colleges, were given a pre-tested questionnaire to be filled. An undertaking was given not to use any data subjectively or to disclose the identity in any other way. To widen the scope of the study clinicians working in the dentistry departments of Medical Colleges, House Officers (M.B.B.S.), and General Duty Medical Officers (GDMOs) were also included in the study. Doctors working in pre- and para-clinical disciplines, those physicians who refused to give written consent, physicians practicing in the allopathic system of medicine without a valid degree or having a degree in some other system of medicine, and physicians having a degree in the allopathic system, but practicing in some other system of medicine were excluded from the study.
In all, the questionnaire had 25 questions divided into five sections. Section-A pertained to the personal information of physicians. Section-B dealt with Essential Medicine; Section-C with the Rational use of Medicine; Section-D with the concept of P-drugs, and Section-E dealt with sources of information.
At the end of the study, all the data was pooled and the results were analyzed in percentage and averages. Univariate analysis, which explores each variable in a data set separately, was carried out by using the Fisher's exact test; which determined whether there was a significant difference between the expected frequencies and the observed frequencies in one or more categories.  A probability value of < 0.05 was considered significant.
| Results|| |
In total, 650 clinicians were contacted. Out of these 650 clinicians 34 clinicians were registered medical practitioners without a valid degree in any system of medicine, 24 clinicians were practicing in the allopathic system of medicine, but were having degrees in the Indian system of medicine, and six clinicians having degrees in allopathic system were practicing homeopathy. Of the remaining 586 physicians eligible for the study, 82 physicians refused to give written consent. Thus a total of 504 fully filled and valid questionnaires were received, giving a response rate of 86% (504 out of 586). Out of these 504 respondents, 280 (55.6%) were males and 224 (44.4%) were females. The age of the study participants ranged from 24 to 61 years. A majority of respondents were having postgraduate degrees (80.2%); 200 were having M.D. degrees, 152 were M.S, 44 were M.D.S., and eight were diploma holders. Out of 84 graduates, 68 were M.B.B.S. and 16 were B.D.S. [Table 1]
Although 84.9% of the clinicians claimed to take care to prescribe an essential medicine, only 46.8% of the physicians were aware of the fact that the new term used now was 'essential medicines' instead of 'essential drugs'. [Table 2] When those physicians who claimed to prescribe EM were furthered questioned, only one-fourth of the physicians said that they always prescribe EM [Table 3]; 28.6% of the physicians had the National Model Essential Drug List (EDL) available at their work place, but ironically none of the participants were aware of the exact number of drugs / drug combinations included in the National Model EDL. Only two clinicians (0.4%) were able to correctly name the part of the prescription slip [Table 2].
Despite a large claim by clinicians that they practiced the rational use of medicine (83.3%); only 15.1% of the clinicians wrote the generic name of the drugs on the prescription slip, while a large number (63.2%) wrote the trade name of the drugs [Table 3]. Moreover, about one-third of the clinicians were not fully aware of the adverse effects, drug interactions, and contraindications of the drugs they used to prescribe [Table 2].
The clinicians were also asked to name all the sources of drug-information used by them. About 83% of the physicians admitted to rely on information from Medical Representatives (MRs), while 69% admitted to use the internet as well. The average numbers of journals prescribed individually by physicians were only 0.6. Similarly, the number of presentations and publications during the last one year were only 0.2 and 0.1 per individual, respectively [Table 4].
On applying the Univariate analysis, it was found that knowledge about the P-drug concept was significantly more in younger clinicians (those aged < 40 years) as compared to those aged ≥ 40 years ( P = 0.007). The statistically significant difference about the P-drug concept was also observed between those clinicians having an experience of < 10 years as compared to clinicians having total experience of ≥ 10 years ( P = 0.012). Interestingly, the concept of RUM was significantly more practiced by females as compared to males ( P = 0.004). The relationship between other variables and use of EM, RUM, and P-drugs was statistically non-significant [Table 5].
| Discussion|| |
Earlier, studies have been conducted to assess the understanding levels of students regarding problem-based learning,  P-drug concept,  and computer-assisted learning. , Studies have also been carried out by clinicians, to assess prescription practices and drug utilization patterns. , This study is unique and novel in the sense that no effort has been made earlier to assess the level of understanding and attitude among the working clinicians, with regard to the prevalent concepts in pharmacology, namely, Essential Medicines, Rational Use of Medicine, and P-drugs; which ultimately leads to rational prescription.
The essential drug concept is an old concept, and over 30 years have passed since it was first mooted. Consequently, a majority of clinicians were aware about Essential drugs, but only one-fourth always cared to prescribe an essential drug. Ironically no clinician was able to correctly quantify the drug / drug combinations in the Indian EDL. This clearly indicates the lack of continued medical education. The other factor may be the market driven forces leading to prescription of new and branded drugs. Essential medicines do not simply mean cheap medicines for poor people in the rural areas of developing countries; they are the most cost-effective treatment for a given condition. Time and again, evidence has shown that clinical guidelines and lists of essential medicines improve the quality of care and lead to better health outcomes.  Accordingly, their use should be encouraged.
For the propagation of RUM in India, the All India Drug Action Network was founded in 1982. Since then, it is active in the campaign for RUM.  Despite the fact that 83.3% of the clinicians claimed to practice RUM, only 15.1% wrote the generic name of the drug, only two could write parts of the prescription correctly, and only 71.4% of the clinicians had complete knowledge of the ingredients of the medicament prescribed. Full awareness about the adverse effects, interactions, and contraindications of the drugs being prescribed was lacking in 32% of the clinicians. Moreover, there was heavy reliability and dependence on MRs for drug information. Time and again, all these factors have been labeled as lures promoting irrational prescription habits leading to irrational use of medicine. Lack of full information about adverse effects, drug interactions, and contraindications can lead to iatrogenic diseases causing more in-hospital admission and loss of resources.  Establishing independent drug information centers in order to cater to the demand of clinicians for having authentic information about a drug can very well decrease the dependence on MRs and can check this menace. 
In a study conducted in Niger, almost 100% of the prescriptions in the name of essential and generic drug in the national drug list were reported; although only 50% of the prescriptions were correct according to the standard treatment guidelines.  Another study carried out at a non-government organization in India reported that 46.2% of the drugs were prescribed by generic name, but 45.6% of the prescribed drugs were irrational drug combinations. Only 45.7% of the prescribed drugs were according to the WHO model list of essential drugs.  Another Indian study reported 73.4% drug prescriptions by generic name. Moreover, 90.3% of the drugs prescribed were from the WHO model essential drug list, but no copy of an essential drug list was available with the clinicians. 
In the present study 84.9% clinicians admitted that they took care to prescribe essential drugs and 83.3% admitted to practicing RUM; but only 25.2% clinicians always chose to prescribe essential medicines and only 15.1% clinicians always prescribed drugs by the generic name. The low turn-out in the present study may be due to the fact that in the present study clinicians from both the tertiary care set-up and the periphery were involved; and not from only one set-up as in the above- mentioned studies. Moreover, it was a multicentric study. Above all, in the present study, prescriptions were never evaluated and results were compiled based on the admissions made by the clinicians themselves. It might be possible that in the evaluation studies reported earlier, ,, clinicians were prescribing essential drugs, unaware of the fact that they are essential drugs.
P-drug is rather a new concept and in India, this concept started gaining importance only in the last two to three years. ,
Sometimes a great deal of heavy debate still takes place among academicians over the choice of a P-drug for a particular condition. , Accordingly, only 23% of the physicians are aware of the P-drug concept and only one-fifth claimed to practice it, clearly indicating the need to arrange more CME on this issue.
A significant difference with regard to practicing the P-drug concept between younger clinicians (age < 40 years, experience < 10 years) and experienced ones may again be due to the same fact that the P-drug concept is a rather new addition to the curriculum and had came into existence much after many clinicians had left the Medical Colleges. A more frequent RUM by females simply reflects a more vigilant, careful, and tactful resource-handling approach by them.
Research orientation among Physicians working in teaching hospitals seems to be lost. Individual subscription rate for journals was only 0.6; while the number of CME attended during the last one year was 0.8 per individual. On an average each physician presented only 0.2 posters / articles and published 0.1 articles during the last one year. The loss in interest in research activities might be due to the fact that in the earlier teaching eligibility criteria as prescribed by the Medical Council of India, requirement of research publications was only a desirable qualification for promotions to higher ranks.  However, with the implementation of the new amendments from August 2009, the requirement of research publications have been made mandatory by the Medical Council of India (MCI).  Therefore, hopefully conditions will improve in the future.
In conclusion, prescribing drugs by trade name, prescribing new drugs, and dependence on MRs for medical information points to clear-cut favoritism toward the market-driven forces, thus leading to irrational prescription behavior and irrational use of medicines; while lack of knowledge about the P-drug concept and the present EDL and RUM underlines the need for arranging continued in-service medical education programs of basic pharmacological concepts for physicians. More independent drug information centers need to be established. It is urgently required to liberate these pharmacological concepts from classroom custody and implement them in pragmatic and field situations.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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