Volume 168 Issue 7

Attitudes to and use of a modified prescription form by general practitioners and pharmacists Merilyn J Liddell and Sue P Goldman MJA 1998; 168: 322-325 For editorial comment see Roberts Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To evaluate the rate of use and acceptance of a new prescription form designed to provide more information to pharmacists and patients. Design: Prospective descriptive study. Setting: A semi-rural community outside Melbourne, Victoria, in November 1994. Participants: GPs and pharmacists working three or more sessions per week in the locality, and 21 consumers who formed two consumer focus groups. Intervention: An education session for GPs and pharmacists, followed by a one-month trial of new prescription forms which included notations to facilitate interprofessional communication. Main outcome measures: Rate of use and acceptability of the new prescription notations. Results: Eighteen GPs and 10 pharmacists participated; 3600 forms were issued and 2521 prescriptions, including 3464 prescription items, were analysed. GPs and pharmacists used at least one of the new prescription notations in 45% (1559) of prescription items; 35% of prescription items (1222) were notated with the general purpose of the medication. Qualitative findings suggested that GPs, pharmacists and consumers considered the new prescription form to be beneficial and useful. Conclusions: A modified prescription form to increase communication between GPs and pharmacists is acceptable in clinical practice. Introduction Over recent years professional standards for prescribing have emphasised the need for a more patient-centred approach,1 as shown in such documents as the National Health and Medical Research Council's guidelines for medical practitioners on providing information to patients,2 the Policy on the Quality Use of Medicines developed by the Commonwealth Government,3 and regulations on the provision of written consumer information with dispensed medication.4 Research on how to provide more patient-centred pharmaceutical information and counselling shows that closer collaboration between general practitioners (GPs) and pharmacists would help to ensure that medication information is both comprehensive and relevant for consumers.5,6 A joint working party of the Royal Australian College of General Practitioners (RACGP) Victoria Faculty and the Victorian Branch of the Pharmaceutical Society of Australia (PSA) was formed in 1993 to consider how to improve communication between GPs, pharmacists and consumers. A series of recommendations were developed and endorsed by the national executives of the RACGP and the PSA, and published in a joint statement.7 The major recommendation was the use of a new prescription form to aid communication between GPs, pharmacists and patients. Here, we describe a pilot study to determine the rate of use of, and the attitudes of GPs, pharmacists and patients to, a modified prescription form for use in normal clinical practice. No similar study has been reported in the literature (based on the following searches: MEDLINE, January 1982 - June 1997; International Pharmaceutical Abstracts, January 1970 - December 1996; HEALTH, January 1975 - December 1996; EMBASE, January 1994 - December 1996; Pharmaceutical News Index, January 1974 - December 1996). Methods Ethical approval for this study was received from the Monash University Standing Committee on Ethics in Research on Humans and all subjects gave informed consent for their par ticipation. The study was conducted in November 1994 in a semi-rural community on the outskirts of Melbourne with a population of 25 000. All 24 GPs and 13 pharmacists working three or more sessions per week in the locality were invited to participate; 18 GPs and 10 pharmacists agreed. Twenty-one consumers from existing heart and arthritis support groups at the local community health centre were recruited for two focus groups of eight and 13 participants. Before the intervention, the 18 participating GPs and 10 pharmacists completed separate questionnaires (29 questions for pharmacists and 28 for GPs), which covered demographics and assessed (on a scale of 1 to 5) attitudes to professional roles, interprofessional collaboration and consumers' needs for medication information and counselling. Intervention The intervention began with an educational session for GPs and pharmacists to introduce the modified prescription form on which GPs could notate the purpose of prescribed medications, changes to existing medications and specific patient needs. Some of these notations were unprompted, requiring freehand additions to the prescription, while others were prompted, appearing as abbreviations on the form which could be circled when appropriate (see Box 1). A glossary of the new prescription notations was provided. Box 1 shows the glossary which was provided to pharmacists. During the education sessions, the new notations were explained as follows. The major change was that GPs were encouraged, where they considered it appropriate, to indicate the purpose of each prescribed medication as part of the written directions. For example, -adrenoceptor blocking agents might be notated as "for arrhythmias" or "for blood pressure". Pharmacists could then ensure that their medication counselling was relevant to that particular indication and would include the medication's purpose on the medication label for the patient's information. There was provision for GPs to request that the purpose not be written on the medication label by the pharmacist in certain circumstances (such as to preserve patients' privacy if the nature of their illness was not known to family members). GPs were also encouraged to indicate to the pharmacist if therapy with an ongoing medication was to cease (enabling pharmacists to update their computer records to show that a drug was no longer to be taken, and attempt to withdraw any unpresented repeats from circulation), or if the directions intentionally specified an unusual dosage or quantity to be dispensed. Finally, GPs could circle abbreviations printed on the prescription form to indicate specific patient needs or changes in the medication regimen. Pharmacists could then check the patient had understood changes to directions and amend the computer records accordingly. At the end of the educational session, 200 triplicate prescription forms were issued to each GP for use over one month. The third copy of each prescription dispensed (minus identifying patient details) was collected to determine the use of the new notations. After one month, individual one-hour open-ended, semi-structured interviews were conducted with all participating GPs and pharmacists, covering their overall views on the reformatted prescription, specific issues of practical application and suggested changes. Two separate one-and-a-half-hour focus group discussions with consumers dealt with aspects of the use of the reformatted prescription which would directly affect patients. Data analysis For frequency analysis of the questionnaires and of the prescription data, we used, respectively, the statistical package Genstat8 and the computer database program Access.9 Transcripts of interview data and focus group discussions were coded according to emerging themes around the prescription format and particular notations. The analysis, with the NUDIST program for qualitative analysis,10 concentrated on direct testimonies of views held about the new prescription form. Results The median age of the 18 GPs was 35 years (range, 20-29 to >70 years) and 14 were male. Their median workload was 175 patients per week (range, 50-99 to >200) and 13 had postgraduate qualifications. The GPs' age and sex distribution was similar to that of respondents in a national general practice population survey.11 The median age of the 10 pharmacists was 40 years (range, 20-29 to 50-59 years) and eight were male. Their median workload was 125 prescriptions dispensed per day (range, 50-99 to >200) and three had postgraduate qualifications. Attitudes to interprofessional communication In the questionnaire, 16 GPs (89%) and all of the pharmacists stated that they were in favour of more collaboration with one another. GPs had a reasonably high regard for the local pharmacists -- 13 (72%) did not agree that pharmacists' advice conflicted with their own; 17 (94%) agreed they had a good working relationship with the pharmacists, and none believed that pharmacists contacted them unnecessarily. Seven pharmacists (70%) stated that they enjoyed a comfortable working relationship with GPs; only three (30%) agreed that GPs were not always receptive to inquiries about prescriptions, and five (50%) expected the GP to be responsive to contact about a potential drug interaction. Before the intervention, the concept of including the general purpose of a medication on the prescription was not recognised by seven GPs (39%) and seven pharmacists (70%) as useful or necessary for the pharmacist. However, nine pharmacists (90%) stated that to counsel patients adequately they often needed to ask a patient for more information than was on the prescription. Use of the new prescription form Of a total 3600 prescription forms distributed to the GPs, 70% (2521 prescriptions for 3464 individual prescription items) were collected and analysed. Forty-five per cent of individual prescription items (1559) included one of the new notations. The rate of use of the new notations by the GPs is shown in Box 2. The purpose of the medication was notated for 35.3% of all prescription items (1222), with use of this notation by individual GPs ranging from 1% for the lowest user to 92% for the highest user. In only 0.3% (range, 0-4.5%) of cases where this notation was used did doctors request that the information be omitted from the label of the medication container. Attitudes to the new prescription form Overall, the new system was positively received by most GPs and pharmacists, and they suggested it should be widely implemented. Also, most GPs and pharmacists saw indicating the purpose of the medication on the prescription as the most substantial and important focus of the new prescription notations, and suggested that this would enhance the quality of information provided to consumers and minimise irrelevant or inappropriate advice. Further, some suggested that compliance may be improved because patients would receive consistent advice from GPs and pharmacists. Most GPs and pharmacists considered it useful to note when therapy with a long term medication was to be ceased, as patients may forget verbal instructions by the GP. Although the need did not often arise in practice, both GPs and pharmacists were in favour of specifically informing the pharmacist when an unusual dosage or a special quantity of medication was being prescribed. Most GPs and pharmacists thought it appropriate to indicate a new treatment, primarily for ongoing management. Noting a change of directions was considered useful by doctors and pharmacists alike, particularly with elderly patients or those who might still have unused prescriptions. The pharmacist could then be sure the change was intended, check the patient had understood the change, amend any unpresented repeats available, and note the change in the pharmacy computer record. Many GPs, pharmacists and consumers regarded preprinted abbreviations for specific patient needs as unnecessary; it was suggested that longhand could always be used for these or other specific requests to the pharmacist. The abbreviation for noting when separate written instructions had been given to the patient was considered a simple and useful quality control mechanism by doctors, pharmacists and consumers. The consumer focus groups indicated that pharmacists needed to know why someone was being prescribed a medication to enable them to provide appropriate counselling. They expressed reservations about conditions of a very personal nature; in such cases they expected the doctor to either ask their permission or omit the information from the prescription. In general, they considered it both appropriate and helpful to have the purpose of the medication included on the medication label. Discussion In this study the questionnaire findings gave basic data about pre-existing attitudes of the GPs and pharmacists to their respective roles, while the qualitative data explored, in much more depth, the strengths and weaknesses of the new innovation. A 70% return rate of prescriptions was satisfactory, as non-redemption of prescriptions can range from 5%-20%.12 Our most notable finding was the utilisation rate of the new notations, with 35% of prescription items indicating the purpose of the medication to the pharmacist. This was somewhat unexpected, as such a strategy had not previously been considered necessary by GPs or pharmacists. Further, such a high utilisation rate requires considerable behaviour change, and behaviour change strategies generally have much more modest outcomes (eg, 6% for minimal intervention smoking cessation programs13 and 8%-25% for group counselling14). The benefits of asking GPs to indicate the purpose of the medication on the prescription were supported by the qualitative data suggesting that when this strategy was employed it was highly valued. Both GPs and pharmacists indicated that the new prescription form would improve the quality of information given to patients by ensuring that information given by pharmacists was consistent with the advice already given by the GP. It would also enable more information to be given to patients on the medication label. It was of particular interest that, while some of the GPs and pharmacists had very high workloads, they were able to use the new prescription conventions easily in their normal daily practice. There was a high level of utilisation of the new prescription form as a whole, with some notations being used frequently, and others barely at all. This is to be expected as the appropriate circumstance for the use of some notations (such as unusual dosage) would be infrequent. The notation to pharmacists that drug therapy was to be ceased was not widely used, possibly because this affected only a small number of patients, but more likely because there was no specific reminder on the prescription form itself and doctors may have simply forgotten to use it. While some variation in the use of notations may have related to differing perceptions of their value, it was probably also a result of the difficulty of altering ingrained behaviour. Some participants stated that they would try to increase their use of the strategies if they were implemented in the future. Indicating the purpose of the medication is easily misinterpreted as being the same as including the diagnosis, and thereby providing unnecessarily detailed and confidential information to the pharmacist. Participating GPs, however, reported that they provided general information at an appropriate level for the pharmacist and, subsequently, the patient. From the pharmacists' perspective, information about the purpose of a medication was most useful for drugs with multiple indications. It enabled them to target their information appropriately without asking questions to ascertain the precise indication for a particular patient. Generally, consumers thought that including the purpose of the medication on the container label was likely to enhance patients' understanding of their own medication. Confidentiality needs always to be considered, but there are clear advantages in having a drug's purpose included on the label in most situations. As we used only two small consumer focus groups, they could provide only a limited indication of what consumers may think of the proposed system. However, consumers did suggest that the new system would help them gain access to appropriate information and advice. Any future implementation should be made with adequate consumer input, to ensure attention to their requirements. In conclusion, this study showed that it is possible to modify the prescription form to include more information in a way that is acceptable to GPs and pharmacists in their daily practice. GPs, pharmacists and consumers found such changes worthwhile and believed they could lead to better medication management and patient care. Acknowledgements We thank the Royal Australian College of General Practitioners and the Victorian Branch of the Pharmaceutical Society of Australia, and the members of the joint working party -- Val Constable, John Daffey, David Dammery, Chris Hogan, Alistair Lloyd, Mary Murray and Denise Ruth -- as well as the GPs, pharmacists and consumers in the study. Finally, we thank the Department of Health, Housing, Local Government and Community Services for financial support for the project. References Liddell M. Rational prescribing and professional standards. Med J Aust 1994; 160: 564-567. Working Party of the Health Care Committee, National Health and Medical Research Council. General guidelines for medical practitioners on providing information to patients. Canberra: National Health and Medical Research Council, 1993. Commonwealth Department of Health, Housing and Community Services, in conjunction with the Pharmaceutical Health and Rational Use of Medicines (PHARM) Working Party. A policy on the quality use of medicines. Canberra: Commonwealth Department of Health, Housing and Community Services, 1992. Part 2A, Schedule 12 of the Therapeutic Goods Regulations under the Therapeutic Goods Act 1989, Section 63. Murphy B, Ruth D, Murray-Hodge M. The use of qualitative research in the development of the HEARTWISE program for general practitioners. Med J Aust 1993; 158: 626-628. Ruth D, Hodge M, Murphy B. Improving the relationship between general practitioners and pharmacists. Aust Fam Physician 1994; 23: 1536-1540. Royal Australian College of General Practitioners and the Pharmaceutical Society of Australia. General practitioners' and pharmacists' interprofessional communication. Aust Fam Physician 1994; 23: 1544-1546. Genstat [computer program]. Version 5 Release 3.1. Lawes Agricultural Trust (Rothamstead Experimental Station, UK), 1993. 9. Access [computer program]. Version 2.0. Redmond, Wa.: Microsoft Corporation, 1994. Richards T, Richards L. The NUDIST qualitative data analysis system. Qual Sociol 1991; 14: 307-325. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157 Suppl Oct 19: 14. Beardon P, McGilchrist M, McKendrick A, et al. Primary non-compliance with prescribed medication in primary care. BMJ 1993; 307: 846-848. Kottke T, Battista R, DeFrieze G, et al. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988; 259: 2882-2889. Curry S, Marlatt G, Gordon J, et al. A comparison of alternative theoretical approaches to smoking cessation and relapse. Health Psychol 1988; 7: 545-556. (Received 5 Jun, accepted 10 Nov, 1997) Authors' details Department of Community Medicine and Department of General Practice, Monash University, Melbourne, VIC. Merilyn J Liddell, MB BS, FRACGP, Senior Lecturer; Sue P Goldman, BEd, GradDipSoc, Research Fellow. Reprints will not be available from the authors. Correspondence: Dr M J Liddell, 867 Centre Road, East Bentleigh, VIC 3165. E-mail: merilyn.liddell AT med.monash.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Merilyn J Liddell · Sue P Goldman

Healthcare and the information age: implications for medical education Simon Carlile and Ann Jervie Sefton The information age, combining rapidly developing information technology and massive growth in biomedical and clinical data, is placing special demands on healthcare workers. Further, radical changes in access to information in our society are affecting the doctor-patient relationship. These changes necessitate a new approach to primary and continuing medical education. A number of imperatives for medical education are identified and some practical changes to a medical curriculum are described. MJA 1998; 168: 340-343 For editorial comment see Coiera Introduction - The information age - Management of healthcare - Information technology and medical institutions - Information technology in general practice - The changing patient-doctor relationship - Information technology and medical education - The direction of curriculum change - References - Authors' details - - ©MJA1998 Introduction More than two decades ago Alvin Toffler wrote prophetically about the need to recognise and manage the dramatic changes that he foresaw in our society.1 That change is certainly upon us and, as predicted by Toffler, is being driven by a multitude of technological and economic developments. In particular, the rapid development and popularisation of the Internet and the World Wide Web (WWW) have profoundly changed the accessibility of information for medical practitioners and their patients. Moreover, rapid developments in the basic and clinical sciences and in diagnostic and therapeutic technologies place their own particular pressures on medical practitioners. Now, more than ever before, we need to be equipped with the mental attitude and intellectual tools to deal with and to exploit such changes. Primary and continuing medical education needs to play a principal role in this process. Education needs a fundamental change of focus from simply delivering content to developing the ability to manage these changes. "Learning to learn" and "learning for life" should be a major guiding influence in curriculum development.2,3 In this article we examine the "information age" and explore its implications for medical education and future practice. The information age The fusion of computing and communications is considered the defining characteristic of the information age. For medicine, such changes need to be examined in the context of the explosion of relevant information from the basic and clinical sciences. The Internet and the World Wide Web The simplest manifestation of the information age is the popularisation of the Internet through the advent of the WWW. The digitisation of information and the globalisation of digital communications has been ongoing for more than three decades4 (see the Box). While the WWW is a relatively recent phenomenon, nearly every relevant economic, social and technological pointer indicates that, at least in Western society, what we are currently seeing is simply the bow wave of its impact.5,6 One principal effect of the WWW has been to shift the emphasis from institutions (public or private) to individuals as publishers of information. It has been argued that, as the users of this technology increase in number and degree of sophistication, this so-called "democratisation" of information will change many of our social institutions. For instance, the political process will undoubtedly be affected by the increased availability of government documents, court rulings, and an increased variety of political commentary (see the website at http://www2.eff.org/pub/Activism/). Similarly, the nature of education will change with the increased availability of on-line courses from a global range of institutions, together with appearance of just-in-time training (allowing selection of training programs when they are needed). This impact is likely to be greatest for institutions that rely on controlling particular types of information to maintain authority. In medicine, the doctor-patient relationship is likely to be affected by the increased availability to patients of medical information. Information technology and the information explosion in biomedical science Biomedical science, in which more than two million journal articles are currently published annually,7,8 is far too broad a discipline for individuals to be able to cover more than a small fraction of current content, let alone keep up with developments outside their own specialties. For medicine, the information explosion brings with it an increase in treatment options, accompanied by an increase in the possible treatment combinations and possible interactions. While dissemination and use of such information remains a problem, information technology (IT) is providing partial solutions. For example: Drug and prescription databases provide a means of checking for misprescriptions and alerting for interactions.9 The challenge here is to deploy such systems widely, and to educate practitioners about their advantages. Ongoing digitisation of patient information will greatly facilitate the assessment of treatment outcomes. The challenge in this area is to distribute this information efficiently and promptly. This has been met, to some extent, by the moves toward so-called evidence-based medicine.8,10 However, evidence-based medicine is itself critically dependent on the development of tools for, and training in, navigation, collation and timely assessment of the relevant literature10-12 (see particularly the website at http://hiru.mcmaster.ca/cochrane/default.htm). The development of such tools begins to address the problem of evaluating the ever-increasing volume of data. However, simply deploying technology for accessing this information is an inadequate response. Doctors need to become independent in their capacities to review and select the most valid and relevant information quickly and efficiently, and medical educators must address this need. Management of healthcare A recent Commonwealth Scientific and Industrial Research Organisation report indicates that the cost of healthcare has risen steadily from 5% of gross domestic product in 1960 to almost 9% today.13 This report is based on Australian and United Kingdom foresight studies which indicate that appropriate deployment of IT will play a role in containing health costs, principally through improving the mechanisms of collection, analysis and sharing of relevant data. As a result, investment in IT by health authorities is almost certain to increase in an effort to gain efficiencies and cost savings in the healthcare sector. Information technologies are already having a major impact on areas such as medical imaging and pathology. Image manipulation, remote consultation and patient records are increasingly managed by means of various forms of IT.11,14 While the interfaces to these systems are generally relatively straightforward, the current lack of standards is unhelpful, requiring an unnecessarily high level of sophistication for users to be able to generalise across systems. The development of an electronic patient record, which has been the focus of considerable effort both in Australia and internationally,15 will provide the basis for considerable improvements in standards for data access and manipulation.16 The development of standards for both electronic patient records and the interfaces that allow manipulation of these data should be driven by the data-handling needs of clinical users so that appropriate strategies are used. Data-access methods that are unnecessarily complex and user-unfriendly lead to a loss of user confidence and resistance to their use. Further, training -- informed by and designed for the healthcare workers using these systems -- is necessary. Such an approach will be an essential ingredient in the acceptance and success of such systems. Information technology and medical institutions In the medium term it is likely that hospitals will be equipped with bedside workstations, which would use a consistent user interface and provide the following kinds of data: all current vital signs and a history since admission; biochemical, haematological and pathology laboratory results; radiological and other diagnostic imaging data; prescription entry coupled with dosage and interaction checking; and report generation. Such technology is already in place today in the neonatal intensive care unit at the New Children's Hospital at Westmead (Sydney, New South Wales).17 This is seen by many as a pilot project for applying these kinds of technologies throughout that hospital. Accordingly, the New Children's Hospital also has a state-of-the-art IT infrastructure, a computer on every desk with universal e-mail access, and a film-less radiology department. Electronic mail and messaging are used heavily by most hospital staff. Without even looking over the technological horizon, a number of straightforward estimates can be made regarding the kinds of technologies very likely to be deployed within the next five years. The clinical environment of the near future, based on extant technology, will include: hand-held wireless terminals with colour screens, voice recognition and very powerful processors; integrated digital patient record systems that cover all points of clinical encounter; intelligent software agents (that are responsive to the patterns of a user's needs) for data retrieval and data management; and generalised diagnostic decision and prescription support systems. These are all systems that are currently in development or beginning to be trialled in different work environments. Information technology in general practice Among studies of the current and projected use of IT by general practitioners,18 many have been aimed at identifying areas where significant value or functionality could be added to the activities of a general practice using desktop systems and the Internet. Services identified included: prescription support and tracking; online access to pharmaceutical information (such as MIMS) and adverse reactions databases; links to international medical digital libraries (eg, MEDLINE, Cochrane library); patient advisory services and websites; information reviews, international journal watches; local and wider area medical news groups and forums; and continuing medical education programs. Many of these kinds of services are already available from providers such as the MIMS medical network or Internet service providers such as Mediserve (NSW, Australia), Health Communication Network Ltd (Australia) or Health Net (Australia). These systems exploit rapidly evolving technologies centred on the WWW as the principal means of delivery. The only certainty about these technologies is that their character and role will change dramatically over the short to medium term. However, as they are currently being exposed to the most stringent form of market testing -- that by relatively unsophisticated users -- their evolution will result in increasingly intuitive and transparent interfaces. The changing patient-doctor relationship The WWW is shaping up to be the world's greatest repository of rapidly accessible information, although this is uncatalogued in any conventional way. To date, the major search engines have indexed every word on more than 30 million Web pages. However, as yet there are no agreed protocols for renewal and evaluation of the information on the WWW, although there are a number of guidelines available (eg, http://www.science.widener.edu/~withers/inform.html), and the WWW consortium which sets internationally agreed standards has a number of working parties exam ining these issues (see http://www.w3.org/TandS/ and http://www.w3.org/PICS/). The number and type of websites is increasing exponentially (see the Box), and, although many sites contain information of little educational worth,19-21 there are also many very useful sites. The implications for medicine are that this is an information resource that is accessible by an increasing number of patients, and in many cases is being contributed to by patients. A keyword search on "HIV" using the AltaVista search engine provides pointers to about 300 000 pages of information on the WWW. Self-help and support groups for an increasingly large range of diseases and disorders provide complex indexes and WWW navigation trails to these information sources. In addition, local medical groups are increasingly looking to provide their patients with relevant information and pointers to the best information available internationally, and clinicians and hospitals are publishing on the WWW to provide local information and advice. It is important to recognise that patients will increasingly turn to such sites for medical and other information over the next few years. Patients are likely to become more medically literate and, as a consequence, there will need to be a shift in the doctor-patient relationship that focuses on sharing resources and negotiating treatments.22 Practitioners will need not only to review and evaluate relevant sites regularly, but also to offer advice on locating accurate and up-to-date information. Patient access to information on best practice will also have important implications for the centralised management of healthcare. For example, treatments that are favoured for their cost effectiveness may not always correspond with what a patient sees as his or her own most effective treatment.23 Information technology and medical education The combined pressures of the information explosion, administrative and fiscal pressures towards digital management and advances in diagnostic and therapeutic technologies all require a reasonable level of IT sophistication from medical practitioners and other healthcare workers. Information technologies are slowly being integrated into secondary and tertiary education.24,25 However, the way in which these technologies are generally being deployed in medical education needs to be radically overhauled. More often than not computers, computer-based education and informatics are offered as ancillary courses or additional learning resources. To be effective, it is essential that this training be integrated deeply into the medical curricula.26 Effective training must exploit the information and procedural models that are currently used and most likely to be used in future medical practice. Further, as a generation in computing terms has shrunk to around 18 months for both hardware and major systems developments, there is a need to emphasise generic computing skills rather than specific packages and interfaces. A recent survey of the directors of clinical training in teaching hospitals in Sydney indicates that the level of IT competency among interns and residents is generally low.27 Exacerbated by a lack of interface standards, such doctors are reported to have difficulty with generalising across different hospital systems to access the information they need in their clinical practice.27 In the area of fellowship training and in continuing medical education, IT competency is also important, as it provides access to a range of flexible teaching and learning options such as self-pacing, customisation and self-evaluation that are, in general, not being exploited at this level. These are very important messages for those who educate our doctors. The pedagogy needs to change significantly to enable tomorrow's doctors to manage and exploit the technological change necessary to cope with the information management demands that will come from their profession and their patients. There is no simple technological solution. The necessary change involves alterations in the way educators and practitioners incorporate information into their practice. Educators need to focus on the processes of learning and on reinforcing the natural curiosity that underpins an attitude of "learning for life".3,28 Doctors need to be able continually to evaluate new information that informs clinical practice in the context of evidence-based medicine.8,29 This capacity requires a range of intellectual and technical tools together with a flexibility of approach that has not been apparent in many mainstream medical curricula. For instance, there is generally a stark contrast between the didactic educational model in the preclinical years and the problem-solving required in the course of normal medical practice. This is being addressed by curricula developed at the Newcastle Medical School and now at the three graduate medical schools (Flinders, Queensland and Sydney).2,3,30 The direction of curriculum change It is clear that IT needs to be an integral part of the medical curriculum, and that the way it is taught needs to reflect the ways students will use these same technologies when they graduate. Such an approach is currently being implemented at the University of Sydney,31 where students are taught to make clinical decisions on the basis of a critical appraisal of the best evidence readily available. Students use computers to access information and learning resources (text, images, websites etc), communicate by electronic mail and electronic forums, consult databases, use word processors and presentation tools for preparing written work, and analyse data using spreadsheets. Translated to clinical practice, ready access to relevant and current data enables informed decision-making, which ensures quality care and can contribute to minimising the costs of that care. Medical education also needs to prepare students for changes in the doctor-patient relationship. Placing appropriate emphasis on personal and professional development helps students develop skills in evaluating the quality of information and in communicating their conclusions to increasingly literate patients. References Toffler A. Future shock. New York: Random House, 1970. Henry RL. Curricula and courses -- implementation of a philosophy at Newcastle, Australia. Ann Community-Oriented Education 1994; 7: 79-92. Sefton AJ. Australian medical education in a time of change: a view from the University of Sydney. Med Education 1995; 29: 181-186. Hafner K, Lyon M. Where wizards stay up late. New York: Simon and Schuster, 1996. Negroponte N. Being digital. Boston: Media Technologies, 1995. Stoll C. Silicon snake oil: second thoughts on the information highway. New York: Doubleday, 1995. Hancock L. Physicians guide to the internet. Philadelphia: Lippincott-Raven, 1996. Sackett D, Rosenberg W, Gray J, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72. Sittig D, Stead W. Computer-based physician order entry: the state of the art. J Am Med Informatics Assoc 1994; 1: 108-123. Sackett DL. Evidence based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997. Coiera E. Guide to medical informatics, the internet and telemedicine. London: Chapman & Hall, 1997. Cochrane AL. Effectiveness and efficiency. Random reflections on health services. London: Nuffield Provincial Hospitals Trust, 1972. Commonwealth Scientific and Industrial Research Organisation. A submission to the House of Representatives Standing Committee on Family and Community Affairs: Inquiry into health information management and telemedicine. 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Simon Carlile, BSc(Hons), PhD, Sub-Dean (Information Technology); Ann Jervie Sefton, MB BS, DSc, Professor, and Associate Dean (Curriculum Development). Reprints: Dr S Carlile, Department of Physiology, F13, University of Sydney, NSW 2006. E-mail: simonc AT physiol.usyd.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

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