Understanding Undergraduate Medicines Optimisation Education and Its Importance; a Realist Evaluation

Introduction: Problematic polypharmacy (PP) is associated with risks and burdens for patients, and waste for healthcare systems. To overcome this challenge, clinicians must be able to tailor clinical decisions to patients’ individual circumstances by integrating biomedical with biographical accounts of illness. This skillset has not been well defined or taught. Medicines optimisation (MO) is a key clinical activity in tackling PP and can exemplify the practical wisdom required for this integration. How and why MO education works is poorly understood. Our previous work, a realist review of published interventions, addressed this gap by explaining how undergraduate MO education could work but was limited by the thin descriptions available. Here, we develop and refine our explanatory model using primary data.

Methods: This realist evaluation develops the programme theory from our review using primary data from individual realist interviews of clinical and educational MO experts. A realist configurational approach to analysis was employed. The study is conducted and reported in-keeping with RAMESES II standards.

Results: Sixteen experts were interviewed; data were used to refine or refute our previous theorising. Analysis showed MO education which seeks to integrate interpretive practice into clinical decision-making must be sufficiently valued by stakeholders at all levels to garner the allocation of resources required for meaningful engagement with this education. Learners must feel they have permission to practice interpretive medicine when healthcare structures are organised to the contrary, this permission should be actively scaffolded by institutional and workplace context. A perception of critical mass within a community of practice may facilitate the required security in decision-making for ongoing practice.

Discussion: We describe how and why undergraduate MO educational programmes can work to produce important outcomes in tackling the challenge of PP. We suggest how MO educational programmes may also act as practical gateways to routine interpretive practice in broader clinical areas.