A recent article mentioned the high incidence of drug prescribing errors and attributed it mainly to inadequate pharmacology teaching [4]. The pervasive and increasingly close relationship between doctors and the pharmaceutical industry influences prescribing habits and the drug education of doctors. In developed nations like the United Kingdom (UK), a core curriculum in prescribing and therapeutics has been developed for medical schools [5]. A study in Australia demonstrated that interns about to commence clinical practice had significant deficits in their prescribing skills [6]. Most interns were in favor of more teaching of clinical pharmacology in medical schools.

In the Netherlands, preclinical medical students were taught to select, prescribe, and evaluate a drug regimen [7]. Preclinical learning in context led to the use of more rational prescribing modalities by students during their internal medicine clerkships. Problem-oriented or problem-based learning (PBL) in pharmacology has been recommended to improve the prescribing skills of doctors. In a university in Slovakia, a hybrid of PBL and lectures was used to teach medical pharmacology, which improved the decision-making skills of future prescribers [8]. Modifications of PBL with students divided into small groups and each group being further divided into clusters with each cluster working on a particular problem [9] and team-based learning [10] have been used to conduct PBL for large groups of students. A mulitcenter randomized controlled study showed that the exercise of creating a personal formulary was effective in teaching rational prescribing [11]. There is a high probability that a large number of drugs chosen in the formulary will be essential drugs. In the United States, a therapeutics curriculum emphasizes pharmacovigilance and drug safety [12].

In a study conducted in a medical school in Nigeria, students wanted teaching using audiovisual aids and inclusion of clinical pharmacology in lectures [13]. They wanted inclusion of seminars and group discussion and felt pharmacology teaching should be more clinically oriented. In India, most students were satisfied with all teaching methods except lectures, seminars, and pharmacy exercises [14]. Students preferred tutorials, short answer questions, and revision classes. They wanted more clinical pharmacology and bedside teaching. In Mexico, pharmacology is taught during the second year of the course covering both basic aspects and clinical pharmacology. However, it was found that training was sometimes inadequate and drugs were prescribed irrationally [15]. At BP Koirala Institute of Health Sciences, Dharan, Nepal, an exercise on drug utilization was used to introduce students to problems with use of antibiotics and inculcate proper prescribing of antibiotics [16]. A sequential decision making process has been recommended to orient students towards rational therapeutics [17].

In Nepal, pharmacology is taught in an integrated organ system-based manner along with other basic science subjects and community medicine during the first two years of the undergraduate medical (MBBS) course. At KIST Medical College (KISTMC), Lalitpur, Nepal, the department of clinical pharmacology and therapeutics is committed to teaching students to use essential medicines rationally. Students work in groups of ten students each and facilitators rotate among groups [18]. Students learn about essential medicines, analyze prescribing using World Health Organization/International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators, select the personal drug (P-drug) for a particular disease condition, verify the suitability of the selected P-drug for a particular patient, write the prescription (P-drug selection process), and communicate non-drug and drug measures to manage the condition with a simulated patient. Students critically analyze drug advertisements and other promotional materials, solve clinical problems, learn to optimize time spent with medical representatives (MRs), and become familiar with independent sources of medicine information. Student opinion about the sessions was obtained previously and was positive [18]. Detailed feedback about the knowledge, attitudes, and skills of students on completing the practical sessions and the effectiveness of the sessions with regard to particular subject areas/learning objectives has not been obtained previously. The subject areas identified were essential medicines, the P-drug selection process, social issues in the use of medicines, responding appropriately to pharmaceutical promotion, using independent sources of medicine information, using antibiotics rationally, analyzing prescribing using WHO/INRUD indicators, communicating with a simulated patient, and reporting adverse drug reactions. Hence, the present study was conducted with the following objectives:

Problems in this subject area include difficulty in obtaining a copy of the essential drug list of Nepal and in allotting adequate time to the topic because of other subject areas to be discussed. During this exercise we also teach students about generic medicines and brand name medicines, product and process patents, TRIPS, and the Doha declaration, among other topics.

Students develop a set of standard treatments for common diseases and a set of first choice drugs called personal or P-drugs using standard treatment guidelines, formularies, textbooks, and other independent sources of medicine information [19]. The exercise of P-drug selection is being conducted at the Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal [20]. At KISTMC, the exercise has been conducted for the last three years [18]. In both institutions, the method described by Joshi and Jayawickramarajah [17] is followed. The exercise occupies an important place in the practical assessment in pharmacology [21].

A medical humanities module called Sparshanam is conducted for all first year students [22]. During the pharmacology practical, we use role plays and small group activities to explore issues like patient preference for injections, not using antibiotics properly, stopping antibiotics on feeling better, preference for more expensive medicines, patient misconceptions about disease and medicines, and patient difficulty in accessing medicines and health services, among others.

Pharmaceutical promotion is becoming an important factor influencing the use of medicines, even in developing countries like Nepal [23]. Students learn to critically analyze drug advertisements and promotional material, to optimize time spent with MRs, and about disease mongering. Teaching students to understand and respond to pharmaceutical promotion is a challenge for medical educators in south Asia [24]. A survey found over 60% of institutions worldwide had used small group discussions in tutorials or workshops [25] to teach about pharmaceutical promotion to their students. Recently the WHO and Health Action International (HAI) have produced a manual entitled Understanding and responding to pharmaceutical promotion: a practical guide[26] to be used in conducting modules on pharmaceutical promotion for medical and pharmacy students.

Using independent sources of medicine information is an important skill for all doctors. In Nepal, drug information centers are available in many teaching hospitals. At MCOMS, Pokhara, the pharmacology department runs a drug information center in the teaching hospital to provide objective, unbiased information about drugs and therapeutics to prescribers [27], which is also used to train medical, nursing, and pharmacy students. At KISTMC, students use sources like the Nepalese national formulary, Patan hospital formulary, and British national formulary during sessions. Students learn to access and assess the quality of health information on the internet. An internet connection in the laboratory, as suggested, would be useful in teaching about online information sources.

Rational use of antibiotics is becoming an important issue. Improper and irrational use of antibiotics is an important factor responsible for antibiotic resistance. We also conduct an exercise analyzing the rationality of prescriptions, and students correct improper prescriptions. Students learn to select antibiotics using the criteria of efficacy, safety, cost, and suitability. They also learn not to use antibiotics in predominantly viral infections like the common cold and upper respiratory infections.

Prescribing indicators have been widely used to assess prescribing, especially in primary health facilities. A study conducted in a medical school in Turkey showed that prescription audit sessions can be an easy and effective method for reinforcing prescribing skills acquired through rational prescribing education [28]. This exercise could be improved by having students analyze prescriptions at government health facilities during their community diagnosis posting.

Standardized patients have been used to teach clinical skills to medical students in ambulatory care settings [29]. They have been widely used to assess communication skills among both medical and nursing students [30]. Their use in both learning and assessment is widespread. We assess students in communication skills at an objective structured practical examination station using a simulated patient and a structured checklist [20].

Teaching students about ADR reporting and pharmacovigilance is important because as future doctors they are important for the success of an ADR reporting program. At MCOMS, students are taught about pharmacovigilance and an exercise in designing an ADR reporting form has been conducted [31]. A study conducted in the UK and published in 2004 found that only 57% of medical schools featured the yellow card scheme, the spontaneous reporting scheme in the UK in their curriculum [32]. Teaching about pharmacovigilance should sensitize students about the importance of ADR reporting, motivate them to report, and equip them with the skills and knowledge to successfully do so.

Pharmaceutical calculations have been covered for a few cohorts, but the learning has not been systematic. We are planning to introduce this in future sessions.

In 2009, a systematic review of educational interventions to improve prescribing by junior doctors and medical students was conducted [33]. The authors concluded that most studies had only small numbers of participants and had methodological flaws. The WHO ‘Guide to Good Prescribing’ is the only widely used model that has been shown to improve prescribing, and it needs further development. Robust methods of assessment are required to assess the impact of teaching interventions. Studies on the long term impact of educational interventions are lacking, especially in developing nations.

The strength of the study was the high response rate. The study also had limitations. The questionnaire and the scoring system were developed by the authors in consultation with a statistician who also has expertise in medical education. However, the questionnaire was not validated. The free text comments about strengths/unique features of the practical session and suggestions for further improvement were few. Student perceptions were not triangulated with data obtained from other sources.

The overall student response was positive. The knowledge and attitude scores were high. The skills scores were low. The students may require more practice and time to further develop their skills and they will put these skills into practice during their internship training. The authors have shown that it is possible to conduct a practical learning program in pharmacology using minimal resources in a developing country. The study shows the immediate impact of the program has been positive. Studies are needed to assess the long term impact. Prescribing during the internship and in future practice will be the true measure of the success of the program. Students should put their knowledge into practice during future clinical training. Similar programs should be considered in other medical schools in Nepal and other developing countries.