Limited prescribing rights for Trainee Interns

Background
Trainee interns (TIs) used to prescribe some drugs, under supervision, in New Zealand up until the beginning of the 1990s. The act of learning by doing was considered an important part of the transition year between fifth year exams and starting employment as a house surgeon.

Although TIs are not registered medical practitioners they were considered to be acting under “standing orders” issued by a supervising doctor that condoned prescribing a limited range of drugs in specific situations. The practice ceased following a review by the Medical Council of New Zealand (MCNZ). The review was sparked by a high profile situation that involved the death of a patient following too much morphine being prescribed by a trainee intern. This unfortunate event was the result of a series of systems failures and a sequence of errors, rather than simply trainee error.

The review indicated that because trainee interns were not medical practitioners registered by MCNZ, they were not entitled to prescribe drugs.  Also the use of standing orders generally was brought into question.

In 2011 the matter has come full circle, and once again the question of whether limited prescribing rights should be given to trainee interns is being discussed.

There are both positives and negatives to the proposal.

Positives

  • An important part of clinical responsibility is the ability to diagnose, prescribe and know when to pass on responsibility to a senior colleague when out of one’s depth. PGY1s often feel that they are thrown in the deep end in regard to prescribing, having had no background training in this during their TI year. Formalising the teaching of prescribing through doing will improve the skills of a TI. 

Negatives

  • Although managing these issues is a part of practising medicine there is a concern that some TIs will be pressured to prescribe by nurses, doctors and patients.
  • There is a concern that any education value to prescribing will be overwhelmed by service obligations imposed by the District Health Board (DHB).
  • ​Unless the MCNZ formally recognises TIs as having appropriate training to undertake limited prescribing rights under standing orders, TIs are likely to be required to be registered as a health practitioner under the Health Practitioners Competence Assurance Act 2003 (HPCA Act). That in turn is likely to have serious consequences should a TI make an error that impacts (or potentially impacts) on patient health and safety.

The NZMA has considered the issue carefully and makes the following statement.

Position statement
The NZMA considers that granting limited prescribing rights to TIs will be of educational benefit to them, and will ease the move from TI to PGY1. There are however a number of caveats which must be met for this to work for TIs.

  • If limited prescribing rights are granted, there must be strict guidelines regulating the medications that may be prescribed. The NZMA supports a list of medicines which can be prescribed as opposed to a list of those which can’t be prescribed. The onus of responsibility for prescribing must lie with the supervising clinician.
  • Guidelines would also need to include provisions that allow trainee interns the option to get second opinions or defer prescription to the supervisor.
  • Appropriate safeguards need to be put in place to protect TIs from being obliged to prescribe when they do not feel safe doing so and to ensure that good practical training is given in the writing of prescriptions. 
  • Trainee interns should not be subject to the same expectations, and liabilities, of registered medical practitioners. The year is primarily an educational one but with some service elements included. Plans need to be put in place to ensure that any potential for errors in prescribing by TIs are minimised. If however a TI does make an error, they should not be subject to the full force of the disciplinary provisions applicable under the HPCA Act.

 Approved by the NZMA Board July 2011