Introduction 1 2 2 3 4 European Journal of Clinical Pharmacology 5 6 European Journal of Clinical Pharmacology 7 7 In this review, we shall endeavour to indicate the essential aspects of teaching CP&T to undergraduate medical students. To this end, we first describe what is known about the general learning objectives in CP&T that medical students should master before graduation. Subsequently, we focus on an essential (in our opinion) core learning objective: ‘therapeutic decision-making’. We go on to describe how medical students and physicians arrive at a therapeutic decision and discuss the possibilities of teaching medical students rational pharmacotherapy. Finally, we recommend approaches for organising, presenting and assessing CP&T in the undergraduate medical curriculum. From core learning objectives to competencies 4 1 9 8 9 5 8 10 11 8 12 Defining a core curriculum for CP&T as presented by Nierenberg, Walley and Orme is important to defining the shape and boundary of the discipline and may be helpful as part of a medical student's examination. However, in addition to knowledge, physicians must also have prescribing skills in order to prescribe rationally. 1 13 14 Table 1 18 Steps Description Step 1 Define the patient’s problem Step 2 Specify the therapeutic objective Step 3a Choose your standard treatment (P-drug) Step 3b Verify the suitability of your treatment (P-drug) Step 4 Start the treatment Step 5 Give information, instructions and warnings Step 6 Monitor (and stop?) treatment 15 16 In conclusion, in order to improve the competency of future doctors to prescribe effectively and safely, several clinical pharmacologists have attempted to determine what every medical student should master before graduation. A common feature of all of the competencies formulated is that all students must acquire a knowledge of the clinical pharmacology of essential drugs and diseases and must master prescribing skills in order to become competent in the rational prescription of drugs. Therapeutic decision-making Although, as described previously, there are many essential therapeutic skills, the final choice of a (drug) treatment for a patient can be looked upon as a core skill in therapeutics. In order to find effective ways to teach our future doctors, it is important to explore how expert doctors arrive at this final therapeutic decision. 17 18 19 19 20 21 22 23 In order to verify whether this is the right script for the individual patient, two types of diagnostic reasoning may be used – analytical and non-analytical. Analytical reasoning is characterised as a slow and relatively time-consuming process that is carried out consciously and systematically and, if possible, evidence-based. Less or inexperienced doctors, such as medical students, mostly use this type of reasoning, mainly because they do not possess the ability to call up so-called ‘illness scripts’. In contrast to analytical reasoning, non-analytical reasoning is carried out rapidly and subconsciously and is based on experience and pattern recognition. This type of reasoning is used especially by experienced doctors. However, when an experienced doctor is confronted with a complex patient case, he or she will also use analytical reasoning. 1 24 Fig. 1 24  However, in order to validate this hypothetical model, further research should be performed, particularly in terms of how experienced doctors arrive at their choice of treatment. In addition, we need to find out how these experienced doctors differ from less-experienced doctors, such as medical students and interns. The answers to these questions will provide more insight into how we should teach therapeutics to students although it can already be stated that early clinical practice will support the development of treatment scripts by undergraduate medical students. How to teach and learn therapeutics 22 25 26 22 26 28 21 22 29 30 30 setting 31 repeat feedback responsible Apart from the most extreme form of context-learning, which is the clinical setting, different variations with lower levels of concreteness of the context are possible, varying from role-playing sessions with standardised patients in a simulated practice setting to the solution of written patient problems in small working groups and patient demonstrations during lectures. However, there are many ways to improve the setting, such as by using real case histories instead of written patient problems or through the use of video materials, laboratory test results or roentgenograms. 32 2 33 knowledge know how know know how show how performance does action Fig. 2 33  34 In conclusion, based on theories as to how physicians arrive at their therapeutic decisions, context-learning seems to be an effective way to teach CP&T to medical students. It is obvious that the ideal situation, i.e. real practice with real patients, is not always attainable, but various suboptimal forms of context-learning and assessment can be applied. Conclusions and recommendations In this document, the learning objectives of teaching CP&T to undergraduate medical students have been described, with an emphasis on therapeutic decision-making. Based on current theories of cognitive psychology and medical education, we have also discussed context-learning as an effective approach to teaching medical students how to prescribe rationally. 35 teaching learning 7 36 Clinical pharmacologists should play an important role in the development of prescribing skills by teaching CP&T to undergraduate medical students. It is recommended that they formulate a CP&T context-learning curriculum within the medical curriculum – of course, in collaboration with physicians. This curriculum must be based on the final learning objectives of the CP&T education programme in which the required level of therapeutic competence of medical graduates has been determined. In addition, the curriculum must fulfil the criteria of context-learning, i.e. gaining knowledge and skills simultaneously in a (simulated) clinical practice setting. Furthermore, for the sake of clarity, it is stressed that the CP&T curriculum should be a visible part of the medical curriculum and that students must know, from the beginning, the required level of competence when they graduate. Current medical students often do not recognise the various CP&T teaching activities since they are scattered through the medical curriculum. 3 knowledge skills clinical practice 1 Fig. 3 A design of a clinical pharmacology and therapeutics (CP&T) context-learning curriculum (adapted from HJM van Rossum)  In conclusion, effective undergraduate teaching of CP&T is essential to improve rational prescribing and will immunize students against factors that may induce irrational prescribing after graduation. Therefore, based on current knowledge about learning, cognitive psychology and research in therapeutic teaching, a CP&T curriculum should be a prominent part of the medical curriculum. The CP&T curriculum should also be linked to postgraduate and continuing education in order to maintain an optimal competence in rational prescribing after graduating. Finally, to achieve a CP&T curriculum, allies should be found because clinical pharmacologists can and should not work on this alone. Medical students are already allies; they are interested in clinical pharmacology and really want to learn how to prescribe drugs rationally. Physicians should also become allies, since they can provide the clinical context for teaching and can prevent students from copying the bad prescribing habits of some of the physicians that train medical students. Associate clinical pharmacologists must collectively determine the current state and perspectives of the undergraduate education of CP&T in Europe. To this end, a European research project, which is organised jointly by the EACPT and British Pharmacological Society, has recently been started. It will not be easy to convince conservative medical faculties, reasonably comfortable with the current conventions that allow clinical impressions to substitute for systematic accumulation of behavioural evidence, that change (in teaching, ed.) is in order Box 1. Illustration of a CP&T curriculum 4 knowledge clinical practice skills Fig. 4 Outline of a CP&T curriculum  18 3 It is evident that in an integrated or problem-based medical curriculum it will be difficult to organise lectures. However, an advantage of this type of curriculum is that teaching is already centred on patient cases. As a result, clinical pharmacologists can introduce learning tasks with respect to basic and clinical pharmacology and therapeutics. In such a curriculum, it will probably be easier to train students in the six-step approach in small group-teaching sessions and practice prescribing in a clinical setting. 37