Junior Doctor Tips - Advice on Prescribing

I’m going to start off with a disclaimer - I’m literally 2 weeks into FY1 (at the time of writing this!) so my experience with prescribing is limited. The idea of solo prescribing is something I found a little daunting during med school, so I thought it’d be useful to share some of the general advice I’ve gathered from practising with doctors and pharmacists as well as things I’ve learned through personal experience.

Check EVERYTHING if you have any doubt

This one might sound obvious, but I still think it needs to be said. It can be so easy to think you know the dose of something but we’re only human, and when someone has asked you to prescribe something and you’re also trying to write a discharge summary and speak to someone on the phone, it’s easy to make mistakes. In addition, many patients will be on altered doses due to renal function/body weight etc., which can be easily glossed over. At the start, you will probably be checking even the simplest of things like paracetamol, and that’s OK! It’s something that comes with practice and expertise… hopefully!

Speak to your ward pharmacist

Or the on-call pharmacist. Or a random one you see walking in the hallway (accept that they might be busy or keen for a coffee or just not in the mood). They are likely a lot better at this than you and they know EVERYTHING. Worried about sozzling someone’s kidneys with gentamicin? They can advise! Insulin charts giving you a headache? They understand them! Don’t understand all the different morphine preparations? Pharmacists to the rescue! Having an existential crisis? They might be too!

I ask my ward’s pharmacist at least one question a day, and he’s given us some really good teaching and tips. Don’t forget, they aren’t there to catch you out for prescribing errors, they just want to ensure safety.

Utilise other specialities

It’s not just pharmacists who know a lot about drugs. If you have a patient who has an uncommon infection and you’re just not sure what to give them, microbiologists and infectious disease doctors will be your best friends. I’ve heard they have an in-brain database of every pathogen and whether it’s gram-negative, how many cocci it has, and what it’s resistant to.

Specialist nurses and ACPs will also be invaluable in their specific area. They’re very used to caring for patients who all have the same disease, so will be familiar with a lot of the medications and preparations.

Remember to take levels

Some medications, like our good friend gentamicin, require either peak or trough blood levels to be taken to see the concentration. It gets forgotten a lot, which is understandable, but can make things really quite tricky. It may mean that the drug has to be held until levels are taken, which, if you have a very unwell patient, is less than idea. The guidelines for when to take them should be on your hospital’s intranet or wherever you tend to find most other guidelines at work. Some are quite complicated (the gent nomogram still bamboozles me), but I refer you again to your friendly local ward pharmacist! If it needs to be done at a time which you won’t be on the ward, make sure to hand it over to the on-call team to take, chase and action it.

Learn your prescribing system

Our hospital has recently switched to e-prescribing (although A&E and some surgical wards are still on paper charts, and certain things like IV infusion and variable rate insulin are ALSO still on paper, just to make your life lovely and confusing). We had mandatory e-learning to complete, but I’m not gonna lie, I did not absorb even 50% of it. So now I use it and feel like I’m ‘learning on the job’, and probably taking a lot more time than I need to and asking everyone a bunch of questions that I’d definitely know if I paid more attention to the e-learning. For example, I stayed late one evening to convert a patient’s drug chart from paper to online and had to add in ‘just in case’ end-of-life (EOL) medications as this patient was for palliative management. A couple of the EOL meds had dosages/forms that I could not find ANYWHERE on our online system, and it was beginning to frustrate me. After 15 minutes, I found a ‘last days of life’ protocol that added them in their correct forms and doses automatically. Fuming. So, the e-learning might seem dull, but it will save you a lot of hassle in the long run. It also handily checks interactions for you, stops certain antibiotics if they haven’t been reviewed when they need to, and prompts you to do VTE risk assessment (again easily forgotten); big up HEPMA developers, you make my job a lot easier.

In a similar vein, learn where you can find antimicrobial guidelines. Apparently, treating infections is more complicated than just chucking some IV Tazocin at it.

“I ask my ward’s pharmacist at least one question a day, and he’s given us some really good teaching and tips. **Don’t forget, they aren’t there to catch you out for prescribing errors, they just want to ensure safety.”**

Apps will save your life

If you aren’t in a hospital or ward with e-prescribing, the BNF app will become your best friend. Not much more needs to be said, just get it. Check if your hospital has any local apps it uses for things like antimicrobial guidelines, thromboprophylaxis, etc.

Put thought into discharge prescriptions

Your patient is going home! Yay! Can someone do the TTOs (to take out meds) please? It can be really tempting to just prescribe everything they’ve had during their inpatient stay. It makes sense right? They’ve been on it for a reason, after all. But there are a lot of things patients WON’T need at home, or that they only had for a short amount of time (especially if they’ve been an inpatient for a while), such as nutritional supplements, laxatives, antiemetics, etc. So just double check they actually need everything you’re giving them, and avoid sending them home with a medication mountain and wasting precious NHS £££.

Conclusion

I hope this has been useful, and remember, if you’re ever unsure of anything, there are so many people on hand who will almost definitely be able to help!