Clinical pharmacology and prescribing education: An updated medical school curriculum from the British Pharmacological Society.

All authors contributed to the design, conduct and analysis of this work. All authors wrote the manuscript.

The curriculum update has been informed by a modified Delphi consensus process. A steering committee to oversee this process was established by the British Pharmacological Society. Experts in clinical pharmacology education based in the UK were invited to join this committee by application. The final steering committee comprised four clinical pharmacologists and two pharmacologists from medical and science backgrounds, respectively. All members of the steering committee (the authors of this paper) hold substantive leadership and course design roles in education, including leadership of clinical pharmacology and therapeutics within medical degree programmes. They have 13–35 years of experience in the design and delivery of clinical pharmacology education. Nationally, they hold or have held leadership and development roles within the Prescribing Safety Assessment and the British Pharmacological Society. Prior to commencing the Delphi process, the steering committee reviewed the most recent iteration of the curriculum [ 11 ] and made corrections which were felt to be matters of grammar or clear and obvious changes in practice over time. The Delphi process consisted of three rounds. All rounds were conducted electronically. In Round 1, individual surveys were completed in which participants ranked each outcome on a three‐point scale (accept/reject/amend). Items with ≥75% acceptance were left as written, and those with ≥75% rejection were removed. This threshold is in line with other Delphi processes, including in medical education [ 27 , 28 ] All comments on individual learning items were reviewed regardless of acceptance level. Grammatical queries and commentary on matters of style were reviewed and actioned by the steering committee. Additional learning outcomes from reviewers were invited for inclusion in Round 2. Where suggested, these were presented by the steering committee with modification only to reflect consistency of style with the curriculum. In Round 2, participants were provided with feedback on changes from Round 1 alongside new learning outcomes for consideration. This round was completed via an online survey. The participants were asked to accept/reject/amend each section of the curriculum with the same acceptance/rejection criteria. In Round 3, a series of expert panels were convened to discuss any outstanding areas of disagreement, including debate on the use and definition of action verbs. These meetings were facilitated as online discussions by the steering committee. The participants in the Delphi process were identified through invitation of the members of the British Pharmacological Society and by invitations to experts within each medical school in the United Kingdom. Experts were also invited to nominate colleagues with relevant expertise and involvement in pharmacology education. There were no explicit restrictions on qualification to participate in the panel, only a request for training in and active involvement with clinical pharmacology or prescribing education. All educators who opted in to the process were accepted. Participation was voluntary, and appropriate consent was sought for the process and storage and sharing of data. Experts were invited to provide information on their role, experience in education and training route into pharmacology education alongside some demographic details. Provision of personal data was optional. Ethical approval for this work was provided by City St George's, University of London ethics committee (REC reference 2024.0192). Data were stored according to UK data protection regulations. Only fully anonymized results were viewed by members of the steering committee for review of each round of the Delphi process, except for the meetings in Round 3 where opinions were discussed in person (online).

The final curriculum is presented in Table  1 . It is also available as a downloadable document from the British Pharmacological Society website. A total of 40 professionals from medical, pharmacy and pharmacology backgrounds participated in the Delphi process (Table  2 ). The median number of years in pharmacology education was 10, with a range of 2 months to 35 years of experience across stakeholders. Sixty‐five percent of the participants had qualified as medical doctors and 30% were pharmacological science specialists. Forty percent of the participants were women. A list of contributors to the process is provided in Data S1 . Inclusion in this list was by additional opt in consent and so is not the full list of contributors. Ethnicity data were self‐identified with free text and are presented in Data  S2 . Updated clinical pharmacology, therapeutics and prescribing curriculum for medical degrees. Define the terms pharmacology, clinical pharmacology and therapeutics Define the terms drug and medicine Explain the extent of medicines use within society Discuss the societal benefits, costs and harms associated with the use of prescription medicines and illicit drugs Describe the impact of drug development, medicines policy and prescribing choices on the environment Define the terms pharmacology, clinical pharmacology and therapeutics Define the terms drug and medicine Explain the extent of medicines use within society Discuss the societal benefits, costs and harms associated with the use of prescription medicines and illicit drugs Describe the impact of drug development, medicines policy and prescribing choices on the environment Define the term pharmacodynamics Describe the mechanisms of drug action at the molecular, cellular, tissue and organ levels Describe the common targets for drugs, for example, ion channels, receptors, transporters, enzymes, nucleic acid and antibodies Explain the relationship between drug dose and response Explain how a drug can interact with its target (e.g. agonist, antagonist) Explain the effect of antagonists on the dose–response curve of an agonist Explain the concept of receptor selectivity Define the terms affinity, efficacy and potency Define the term ‘therapeutic index’ Describe the phenomena of desensitization and tolerance Define the term pharmacokinetics Explain the four phases of pharmacokinetics Explain why an understanding of pharmacokinetics is relevant to prescribers Explain the mechanisms of drug movement across physiological barriers Explain fundamental differences between various routes of drug administration Describe first pass metabolism and its importance Explain how one drug can influence the absorption of another Explain the distribution of drugs across body compartments Define apparent volume of distribution Explain how the distribution of a drug may influence how it works and how it may be dosed Describe how drugs are metabolized, for example, Phases I and II metabolism Explain the important routes of drug excretion from the body Explain the role of the liver and cytochrome P450 enzymes in drug metabolism Explain why drug metabolism is a potential point of interaction between drugs Describe the typical concentration–time curve for a drug with first‐order kinetics Explain the importance of zero‐order (saturation) kinetics Define clearance and half‐life Define bioavailability Discuss the pharmacokinetic factors that determine choice of formulation, dose, route and frequency of drug administration Explain the pharmacokinetics of repeated dosing including time to ‘steady state’ Explain how half‐life has practical implications for dosing Explain the rationale for loading doses Identify factors (pharmacokinetic and pharmacodynamic/intrinsic and extrinsic) influencing variability in response to drugs and provide common examples Explain how inter‐individual variability in pharmacokinetics can lead to variation in response to a dose of a drug Explain how pharmacodynamic factors can affect drug response (e.g. receptor sensitivity, tolerance, organ‐disease) Identify important groups of people where pharmacokinetics is altered and explain the mechanisms involved and adjustments that may have to be made by prescribers Identify common ways in which genetic and epigenetic variation influences the handling and response to drugs and influences prescribing Explain how knowledge of pharmacogenetic variation can enable safer and more effective prescribing Identify factors (pharmacokinetic and pharmacodynamic/intrinsic and extrinsic) influencing variability in response to drugs and provide common examples Explain how inter‐individual variability in pharmacokinetics can lead to variation in response to a dose of a drug Explain how pharmacodynamic factors can affect drug response (e.g. receptor sensitivity, tolerance, organ‐disease) Identify important groups of people where pharmacokinetics is altered and explain the mechanisms involved and adjustments that may have to be made by prescribers Identify common ways in which genetic and epigenetic variation influences the handling and response to drugs and influences prescribing Explain how knowledge of pharmacogenetic variation can enable safer and more effective prescribing Partnership with patients Explain the importance of, and barriers to, shared decision‐making Describe how the values, preferences and beliefs of patients and prescribers may influence prescribing decisions Define the term concordance Explain ways in which concordance can be improved (e.g. presenting accessible information) Demonstrate the ability to communicate the benefits and risks of drug therapy with patients Demonstrate the ability to explore patients' views and wishes in relation to drug treatment Explain the importance of, and barriers to, shared decision‐making Describe how the values, preferences and beliefs of patients and prescribers may influence prescribing decisions Define the term concordance Explain ways in which concordance can be improved (e.g. presenting accessible information) Demonstrate the ability to communicate the benefits and risks of drug therapy with patients Demonstrate the ability to explore patients' views and wishes in relation to drug treatment Define the terms adherence and compliance Describe the influence of patients' beliefs on adherence Explain non‐adherence and its consequences on an individual and population level Make an accurate assessment of adherence to medication Describe measures to improve adherence (whether intentional or unintentional) Explain how monitoring drug therapy can aid decisions around altering or stopping therapy Describe the ways in which therapy can be monitored including clinical outcomes, pharmacodynamic responses and plasma drug concentrations, and identify the prerequisites, advantages and disadvantages of each approach List common examples where monitoring drug concentration is important Explain why the impact of drugs on clinical outcomes can be difficult to measure Explain the difference between a surrogate and clinically relevant outcome Describe what makes a good surrogate outcome Describe the concept of inter‐individual variability in the relationship between dose and plasma drug concentration, and the relationship between drug concentration and effect Describe the characteristics that make a drug suitable for monitoring by measurement of concentration List common medicines whose use is facilitated by measurement of drug concentration Describe the process of measuring plasma drug concentrations, including the timing of sampling in relation to dose Explain how to interpret drug concentration measurements, including that some assays measure total‐ and some free‐drug concentrations Explain how drug concentration measurements may be used to adjust dosage Define the term adverse drug reaction and other adverse outcomes of drug therapy (e.g. drug toxicity, hypersensitivity) Outline the frequency of adverse drug reactions and their impact on public health Discuss why all drugs have both beneficial and adverse effects and list patient groups most at risk of adverse drug reactions Describe classification systems for adverse drug reactions such as ABCDE or DOTS List factors that may be associated with increased risk of hypersensitivity reaction (e.g. allergy or anaphylaxis) List drugs that are frequently associated with hypersensitivity Explain how to identify and characterize hypersensitivity reactions to drugs Describe the importance of accurate diagnosis and recording of hypersensitivity reactions to drugs Describe the precautions that should be taken to reduce risk of hypersensitivity reactions Explain how to respond if an adverse drug reaction is suspected Explain how to manage a suspected adverse drug reaction Avoiding adverse drug reactions Describe risk factors that predict susceptibility to adverse drug reactions Describe how identification of those risk factors can influence prescribing decisions List important sources of information about adverse drug reactions including the British National Formulary (BNF) and the electronic medicines compendium Explain how warnings in prescribing resources can prevent adverse reactions Explain how monitoring can prevent adverse reactions (e.g. monitoring renal function, drug concentration) Describe risk factors that predict susceptibility to adverse drug reactions Describe how identification of those risk factors can influence prescribing decisions List important sources of information about adverse drug reactions including the British National Formulary (BNF) and the electronic medicines compendium Explain how warnings in prescribing resources can prevent adverse reactions Explain how monitoring can prevent adverse reactions (e.g. monitoring renal function, drug concentration) Explain the ways in which adverse drug reactions can be identified (e.g. drug development, voluntary reporting, record linkage) and outline the limitations of these approaches Explain why the adverse drug reaction profile of a drug may be incomplete at the time of marketing authorization, and how it improves through effective pharmacovigilance Discuss the importance of pharmacovigilance, including the role and responsibilities of the prescriber Outline how to report a suspected adverse drug reaction using the MHRA Yellow Card scheme Explain how drug interactions may cause beneficial or harmful effects Outline the main types of drug interaction (e.g. pharmaceutical, pharmacokinetic, pharmacodynamic) Explain why the potential for drug interactions is increasing, including the impact of polypharmacy and multimorbidity Identify sources of information about drug interactions to inform prescribing including the British National Formulary (BNF) and the electronic medicines compendium Explain how to anticipate and avoid drug interactions Explain how a drug interaction that cannot be avoided could be managed (e.g. dose adjustment, additional monitoring) Describe points of clinically important drug interactions, for example, liver metabolism, cytochrome P450 enzymes and drug transporters Explain how enzyme metabolism can be inhibited or induced and the impact this has on drug handling Explain how drug interactions may cause beneficial or harmful effects Outline the main types of drug interaction (e.g. pharmaceutical, pharmacokinetic, pharmacodynamic) Explain why the potential for drug interactions is increasing, including the impact of polypharmacy and multimorbidity Identify sources of information about drug interactions to inform prescribing including the British National Formulary (BNF) and the electronic medicines compendium Explain how to anticipate and avoid drug interactions Explain how a drug interaction that cannot be avoided could be managed (e.g. dose adjustment, additional monitoring) Describe points of clinically important drug interactions, for example, liver metabolism, cytochrome P450 enzymes and drug transporters Explain how enzyme metabolism can be inhibited or induced and the impact this has on drug handling Define medication errors, including subtypes (e.g. mistakes, violations, slips and lapses) Outline human error theory in simple terms Identify individual and systems factors leading to error Outline the steps that should be taken when a medication error is discovered, including the use of error reporting systems Explain how prescribers and health‐care systems can reduce error, including the use of electronic prescribing Describe how collaboration with pharmacists and other health‐care professionals can prevent errors Outline how drugs are discovered Describe the stages of drug development (Preclinical, Phase I to Phase IV clinical trials) Describe the risks and costs involved in developing drugs Explain the different forms of clinical trial and their advantages and disadvantages Describe the requirements of a good clinical trial including consent, ethics, bias, statistics and dissemination of its findings Explain why drugs need to be regulated and identify the major regulatory authorities in the UK and internationally (e.g. MHRA, EMA and FDA) Outline the approval process for new drugs Describe the implications of market exclusivity and patents, for example, on the range of products available and their cost Outline how drugs are marketed by the pharmaceutical industry and the legal constraints on the marketing process Describe the role of codes of conduct in relation to marketing of drugs (e.g. the Association of the British Pharmaceutical Industry code of conduct and the Medicines and Healthcare products Regulatory Agency blue guide) Describe the potential for marketing processes to change attitudes to a drug and how this can be abused Outline the features of a randomized controlled trial, cohort study, case control study, systematic review and meta‐analysis Explain the difference between interventional and observational studies Identify different kinds of evidence and outline their hierarchy in terms of validity and reliability Discuss the limitations of applying clinical trial data to individual patients Describe the process of critical appraisal of clinical studies and demonstrate the ability to appraise research Describe an approach to identifying methodological flaws, including sources of bias Explain the different types of endpoints or outcomes in clinical trials, for example, patient centred, surrogate, biomarkers and clinically relevant Explain the concept of external validity and problems with extrapolating clinical trial results Identify important information resources that might inform prescribing decisions Describe how prescribers can keep up to date with change Evaluate sources of information for their reliability, for example, websites and online tools Describe how new medicines are assessed on the basis of safety, clinical efficacy and cost‐effectiveness Outline the principles of pharmacoeconomic assessments Describe the roles of guideline groups, for example, the National Institute for Health and Care Excellence (NICE) Outline the role of local and regional committees in medicines management Describe the role of local formularies and guidelines in the choice and use of medicines Describe the factors that influence prescribing choices and why these have to be limited (e.g. cost and antibiotic resistance) Explain the responsibility of prescribers to avoid wasteful prescribing and support sustainability Define ‘clinical guideline’ and outline its purpose Describe the limitations and harms of clinical guidelines Outline the legal standing of guidelines Outline the relationship between the British National Formulary and local formularies Describe the reasons for creating limited lists of medicines Outline the important issues relating to coordination of prescribing in primary and secondary care Identify resources contained within the British National Formulary and describe how they may be used Describe the limitations of the information contained in the British National Formulary Outline the legal categorization of drugs into General Sales List, Pharmacy medicines, Prescription‐only medicines and Controlled drugs Describe who is entitled to prescribe medicines and the legal requirements involved Describe who is entitled to supply medicines and the legal requirements involved Describe the legal requirements associated with prescribing controlled drugs Identify common ways that prescription drugs can be supplied illegally (e.g. internet pharmacy) Describe the circumstances in which drugs are prescribed ‘off‐label’ Explain the additional responsibilities associated with prescribing ‘unlicensed’ or ‘off‐label’ medicines Describe what information should be given to patients to allow them to make informed decisions about ‘off‐label’ treatment Describe the responsibilities of prescribing in a resource‐limited health‐care system Describe the sometimes‐conflicting responsibilities to individual patients and the wider health‐care community Discuss the benefits and costs of adhering to therapeutic guidelines and drug formularies Explain why it is important to recognize limits of competence and to ask for help when needed Explain the responsibility and importance of keeping one's prescribing practice up to date with advances in medical knowledge Describe how impaired liver function may alter physiology, pharmacokinetics and pharmacodynamics List common medicines that are likely to cause harm to patients with impaired liver function Outline the principles involved in selecting medicines and designing dosage regimens for patients with impaired liver function Explain where to find relevant information about choosing and adjusting drug dosage in patients with impaired liver function Describe how impaired renal function may alter physiology, pharmacokinetics and pharmacodynamics List common medicines that are likely to cause harm to patients with impaired renal function Outline the principles involved in selecting medicines and designing dosage regimens for patients with impaired renal function Explain where to find relevant information about choosing and adjusting drug dosage in patients with impaired renal function Describe how advanced age may alter physiology, pharmacokinetics and pharmacodynamics List common medicines to which elderly patients are especially likely to respond differently Explain where to find relevant information about choosing and adjusting drug dosage in elderly patients Outline the principles that underlie prescribing in the elderly Explain the reasons for caution when prescribing for pregnant women and women of child‐bearing potential Describe how pregnancy alters physiology, pharmacokinetics and pharmacodynamics List common medicines to which pregnant women are especially likely to respond differently Describe the possible effects of drugs on the developing foetus, in relation to the stage of gestation Outline the principles involved in selecting medicines and designing dosage regimens for pregnant women and women of child‐bearing potential Explain where to find relevant information about choosing and adjusting drug dosage in pregnant women and women of child‐bearing potential Explain the reasons for caution when prescribing for women who are breastfeeding List common medicines that are likely to cause harm to the newborn as a result of transmission via breast milk Outline the principles involved in selecting medicines and designing dosage regimens for women who are breastfeeding Explain where to find relevant information about choosing and adjusting drug dosage in women who are breastfeeding Describe the changes in physiology, pharmacokinetics and pharmacodynamics in early life List common medicines to which children are likely to respond differently Explain where to find relevant information about choosing and adjusting drug dosage for children Explain the principles that underlie prescribing for children and adolescents, for example, administration, formulation and capacity Make an accurate assessment of patient specific factors when prescribing Select an appropriate medicine based on its comparative efficacy, safety, convenience and cost Explain the importance of identifying diagnosis (if possible) and therapeutic objectives Evaluate the factors that influence the choice of formulation, dose, route, frequency and duration of treatment Demonstrate the ability to review a medication list and optimize therapy Explain the importance of accurate calculation of drug dosage, especially for intravenous infusions Demonstrate the ability to interpret and convert between different expressions of drug concentration or dose Calculate appropriate doses for individual patients, based on age, body weight and surface area Select drug dosage using commonly available nomograms Identify factors that may necessitate amendments of standard doses Describe the epidemiology of poisoning Outline the principles of assessment of a poisoned patient Discuss the role of urine and blood sampling in poisoned patients Describe the clinical features of overdosage with commonly used medicines (e.g. paracetamol, salicylates, tricyclic antidepressants, opioids and benzodiazepines) Outline the principles involved in treating a poisoned patient Explain how to access and obtain information from the National Poisons Information Service (e.g. TOXBASE) List drugs and toxins to which effective antidotes are available and explain the mechanisms of action Explain the means by which the elimination of drugs or toxins can be hastened List drugs that are commonly misused (e.g. cannabinoids, MDMA, hallucinogens, volatile solvents, cocaine, opioids and alcohol) and outline some of their important pharmacodynamic effects Recognize that making, taking, carrying or selling some drugs is illegal and controlled by the UK Misuse of Drugs Act 1971 Explain the extent of illicit drug use and its public health consequences Define tolerance, physical dependence and psychological dependence Describe the prevalence of use of complementary and alternative therapeutic approaches and recognize variation in use between populations Outline the motivations that lead people to seek complementary and alternative therapies Describe common therapies used by practitioners of complementary and alternative medicine and the evidence for their efficacy and safety Explain the potential of complementary and alternative medicines to cause adverse effects, including interactions with conventional therapy Describe the regulation of complementary and alternative medicines Alginates and antacids H 2 ‐antagonists (e.g. famotidine) Proton pump inhibitors (e.g. omeprazole) Antimotility drugs (e.g. codeine and loperamide) Laxatives (e.g. bran, ispaghula husk, senna, lactulose, phosphate and glycerol) Antispasmodics (e.g. mebeverine and atropine) Aminosalicylates (e.g. mesalazine) Biologics (e.g. infliximab) Dopamine D2‐receptor antagonists Histamine H1‐receptor antagonists Serotonin 5‐HT3‐receptor antagonists Hyoscine Vitamins (e.g. vitamin K, B12 and thiamine) Thiazide and thiazide‐like diuretics (e.g. bendroflumethiazide and indapamide) Loop diuretics (e.g. furosemide) Potassium‐sparing diuretics (e.g. amiloride and spironolactone) Beta‐adrenoceptor blocking drugs (e.g. atenolol and bisoprolol) Calcium channel blockers (e.g. amlodipine and verapamil) Nitrates (e.g. glyceryl trinitrate) ACE inhibitors (e.g. ramipril) Angiotensin II receptor antagonists (e.g. losartan) Alpha‐adrenoceptor blocking drugs (e.g. doxazosin) Digoxin Amiodarone Adenosine Anti‐platelet drugs (e.g. aspirin, clopidogrel and ticagrelor) Thrombolytic drugs (e.g. alteplase) Heparins (unfractionated and low molecular weight) and fondaparinux Oral anticoagulants (e.g. warfarin and direct oral anticoagulants) Statins (e.g. atorvastatin) Atropine Oxygen therapy Beta 2 adrenoceptor agonists (e.g. salbutamol and formoterol) Antimuscarinics (e.g. tiotropium and ipratropium) Phosphodiesterase inhibitors (e.g. theophylline) Inhaled corticosteroids (e.g. beclometasone) Leukotriene receptor antagonists (e.g. montelukast) Mucolytics (e.g. carbocisteine) Levodopa and dopa‐decarboxylase inhibitors (e.g. co‐careldopa) Other antiparkinsonian drugs (e.g. ropinirole) Anticonvulsant drugs (e.g. phenytoin, carbamazepine, valproate, lamotrigine and levetiracetam) 5‐HT 1 ‐receptor agonists (e.g. sumatriptan) Acetylcholinesterase inhibitors (e.g. donepezil and rivastigmine) Glutamate receptor antagonist (e.g. memantine) Anti‐platelet agents (e.g. aspirin and clopidogrel) Thrombolytic drugs (e.g. alteplase) Baclofen Benzodiazepines (e.g. diazepam and lorazepam) Z‐drugs (e.g. zopiclone) Tricyclic antidepressants (e.g. amitriptyline) Selective serotonin reuptake inhibitors (e.g. fluoxetine and citalopram) Other antidepressant drugs (e.g. serotonin‐noradrenaline reuptake inhibitors) First‐ and second‐ generation (e.g. haloperidol, olanzapine and aripiprazole) Mood stabilizers (e.g. lithium) Drugs for ADHD (e.g. methylphenidate) Drugs that are misused As with other therapeutics, there are changes with time in drugs that are misused. Some examples include: Ethanol Ethanol Opioids Cannabinoids Amphetamines Cocaine Ketamine Ethanol Ethanol Opioids Cannabinoids Amphetamines Cocaine Ketamine Penicillins (e.g. benzylpenicillin, amoxicillin and flucloxacillin) Cephalosporins (e.g. cefuroxime) Aminoglycosides (e.g. gentamicin) and glycopeptides (e.g. vancomycin) Antituberculous drugs (e.g. isoniazid, rifampicin and ethambutol) Other antibiotics (e.g. chloramphenicol, meropenem, macrolides, nitrofurantoin quinolones, tetracyclines, trimethoprim and metronidazole) Antifungal drugs (e.g. clotrimazole, amphotericin and nystatin) Antiviral drugs (e.g. acyclovir) HIV infection treatment Antimalarial drugs (e.g. artesunate chloroquine) Immunization Insulins Metformin Oral hypoglycaemic agents (e.g. sulfonylureas, thiazolidinediones, dipeptidyl peptidase‐4 inhibitors and SGLT‐2 inhibitors) GLP‐1 agonists Drugs for thyroid disease (e.g. levothyroxine, propranolol and carbimazole) Bisphosphonates (e.g. alendronic acid) Other drugs used in osteoporosis treatment and prophylaxis (e.g. denosumab, calcium, vitamin D, oestrogens and related drugs) Corticosteroids (e.g. hydrocortisone, dexamethasone and prednisolone) GLP‐1 agonists Immunosuppressants (e.g. ciclosporin, azathioprine, cyclophosphamide and tacrolimus) Alpha blockers (e.g. tamsulosin) 5α reductase inhibitors (e.g. finasteride) Gonadorelin analogues (e.g. goserelin) Antimuscarinics (solifenacin and oxybutynin) Phosphodiesterase (type 5) inhibitors (sildenafil) Diuretics (e.g. loop, thiazide and thiazide‐like) ACE inhibitors (e.g. ramipril) Angiotensin II receptor antagonists (e.g. losartan) Female sex hormones (e.g. oestrogens and progestogens) Oxytocic drugs (e.g. prostaglandins, ergometrine and oxytocin) Tranexamic acid Antihistamines (e.g. cetirizine and chlorphenamine) Ocular lubricants (e.g. hypromellose and carbomer) Prostaglandin analogues (e.g. latanoprost eye drops) Emollients Topical corticosteroids (e.g. hydrocortisone cream) Acne (e.g. benzoyl peroxide, topical and systemic retinoids) Permethrin and malathion Cytotoxic chemotherapies (e.g. doxorubicin, cisplatin and 5‐flurouracil) Biologics Hormonal cancer therapies (e.g. tamoxifen and goserelin) Non‐steroidal anti‐inflammatory drugs (e.g. ibuprofen and naproxen) Disease‐modifying anti‐rheumatic drugs (e.g. sulfasalazine and methotrexate) Biologics Drugs for gout (e.g. allopurinol and colchicine) General anaesthetics (e.g. propofol, isoflurane and other volatile agents) Local anaesthetic drugs (e.g. lidocaine) Muscle relaxants (e.g. suxamethonium and rocuronium) Non‐steroidal anti‐inflammatory drugs (e.g. ibuprofen) Paracetamol and combination analgesics (e.g. co‐codamol and co‐dydramol) Opioids (e.g. codeine, tramadol and morphine sulphate) Gabapentinoids Intravenous fluids (e.g. 0.9% sodium chloride, balanced crystalloids, glucose solutions, magnesium, potassium and calcium) Blood transfusion (and other blood products) Adrenaline Adenosine Activated charcoal Atropine/antimuscarinics Calcium chloride/gluconate Naloxone Thrombolytics/fibrinolytics Peptic ulcers (including eradication of Helicobacter pylori ) Gastro‐oesophageal reflux disease Diarrhoea Constipation Nausea and vomiting Functional bowel disorders Irritable bowel syndrome Functional bowel disorders Irritable bowel syndrome Ulcerative colitis Crohn's disease Hepatic encephalopathy and portal hypertension Ascites Alcohol withdrawal Upper gastrointestinal bleeding Adult hypertension Hypertension in pregnancy Stable angina Unstable angina/non‐ST elevation myocardial infarction Acute ST elevation myocardial infarction Acute heart failure Chronic heart failure Atrial fibrillation Bradyarrhythmias Supraventricular tachycardia Ventricular arrhythmias Cardiac arrest Acute and chronic limb ischaemia Deep vein thrombosis Pulmonary embolus Hypercholesterolaemia Pericarditis Acute asthma Chronic asthma Acute exacerbations of COPD Stable COPD Cough and congestion Respiratory failure Hypoxaemia Acute stroke and transient ischaemic attack Primary and secondary prevention of stroke Principles of managing pain (including the analgesic ladder) Neuropathic pain Parkinson's disease Status epilepticus Chronic epilepsy Acute migraine Prophylaxis of migraine Cluster headache Tension headache Vertigo Dementia Muscle spasm Sleep disorders Insomnia Chronic anxiety Panic disorders Chronic depressive illness Bipolar disorder Chronic schizophrenia Acute behavioural disturbance Alcohol dependence Nicotine dependence and withdrawal Opioid dependence and withdrawal Acute gastroenteritis Acute abdominal infections (e.g. appendicitis, cholecystitis and peritonitis) Acute bacterial endocarditis Upper respiratory tract infections Lower respiratory tract infections (e.g. pneumonia and bronchiolitis) Tuberculosis Viral infections (e.g. COVID‐19, influenza) Meningitis Encephalitis Urinary tract infection (e.g. cystitis and pyelonephritis) Epididymitis and orchitis Sexually transmitted infections (e.g. chlamydia and gonorrhoea) HIV infection Cellulitis Surgical site infection Post‐operative peritonitis Sepsis Bacteraemia of unknown origin Clostridium difficile infection Methicillin‐resistant Staphylococcus aureus (MRSA) infection Infection in an immunocompromised host Sepsis in an immunocompromised patient Malaria Management of type 1 diabetes Diabetic ketoacidosis Hypoglycaemia Management of type 2 diabetes Hyperthyroidism Hypothyroidism Osteoporosis Osteomalacia Addison's disease (incl. Addisonian crisis) Hyperaldosteronism Obesity Electrolyte imbalance Chronic kidney disease Acute kidney injury Glomerulonephritis Nephrotic syndrome Cystitis Pyelonephritis Incontinence Over‐active bladder Benign prostatic hyperplasia/enlargement Prostate cancer Erectile dysfunction Hormonal contraception Non‐hormonal contraception (e.g. spermicide, barrier and intrauterine devices) Menopause Polycystic ovary syndrome Endometriosis Pre‐eclampsia Gestational diabetes mellitus Iron deficiency anaemia Macrocytic anaemias Blood transfusion (and other blood products) Anticoagulant reversal Adverse effects related to cancer therapeutics (e.g. chemotherapy–neutropenia, nausea and vomiting) Cancer‐related pain Management of other symptoms in terminal malignant disease Breast cancer Gout Acute gout Prophylaxis of gout Inflammatory arthropathies Rheumatoid arthritis Temporal arteritis and polymyalgia rheumatica Atopic dermatitis and eczema Psoriasis Acne vulgaris Cellulitis and impetigo Urticaria Scabies and head lice Acute glaucoma Chronic ‘open‐angle’ glaucoma Conjunctivitis Uveitis Allergic rhinitis Vertigo Otitis media/externa Throat infections and tonsillitis Antibiotic prophylaxis Thromboprophylaxis Managing and amending regular medication (e.g. warfarin and insulin) Post‐operative pain (including patient‐controlled analgesia) Post‐operative fluid replacement Post‐operative infections Paracetamol poisoning Tricyclic antidepressant poisoning Acute opiate intoxication Acute anaphylaxis Other skin and systemic adverse drug reactions Demonstrate the ability to elicit and document an accurate medication history, including current and recent medicines, to support effective medicines reconciliation Identify, where possible, for each drug the original indication, formulation, dose, route, duration and effects Assess exposure to non‐prescribed agents and therapies (e.g. over‐the‐counter, complementary therapies, alcohol, tobacco, recreational drugs and internet‐sourced drugs) Identify alternative sources of information about current treatment and outline the limitations of these information sources (e.g. electronic medical records, general practice records and carers) Interpret the medication history so that allergies and adverse drug reactions (ADRs) can be identified (distinguish between a history of drug allergy and intolerance) Identify common potentially important drug interactions Identify health concern(s) to be treated Identify the therapeutic objective(s) for new therapy Evaluate the risks and benefits of specific drug therapies Identify drugs with a narrow therapeutic index or high potential for serious adverse effects/interactions, and take appropriate precautions when prescribing them Demonstrate the ability to follow clinical guidelines, protocols and formularies where appropriate Outline economic and sustainability factors within prescribing decisions (e.g. choice of inhaler) Identify possible contraindications, drug–drug interactions, previous ADRs, any special circumstances (including religious beliefs or lifestyle choices [e.g. porcine‐derived medications or excipients]), age, weight, gender and diseases Select the appropriate formulation, dose, route, frequency and duration of a drug Interpret data that are relevant to prescribing decisions (e.g. renal function and drug concentrations) Record the rationale for new prescribing decisions in the medical record Identify and reduce the risk of medication errors Identify situations where one's own prescribing skills are not sufficient and seek advice before proceeding Identify situations where non‐pharmacological approaches may be more appropriate Prescribe in written and electronic form Calculate appropriate doses using individual patient data such as body weight, surface area, organ function and based nomograms where appropriate Convert doses between common units and convert between concentrations expressed as percentage and mass by volume Calculate equivalent doses when changing drug or pharmaceutical formulation (e.g. corticosteroid and opioid) Write an unambiguous, legible, complete and legal prescription (approved name, appropriate form and route, correct dose, any other necessary instructions, and signature), avoiding abbreviations and ambiguities (e.g. writing micrograms in full) Prescribe ‘once‐only’, regular and ‘as required’ medicines Prescribe on hospital supplementary prescription charts (e.g. insulin and anticoagulants) Prescribe ‘to take out’ drugs on discharge from hospital Prescribe on general practice prescription forms (e.g. FP10) Keep accurate records of prescriptions and drug responses Discontinue prescriptions appropriately Engage in shared decision‐making Communicate a treatment plan Offer guidance about safe and effective ways to take specific medicines (e.g. bisphosphonates and inhalers) Discuss important and common adverse effects and when to discontinue medicines or seek help if these occur Communicate treatment plans and monitoring arrangements clearly with other members of staff, in both verbal and written form Keep accurate written records of management plans Write accurate discharge prescriptions and letters to other health‐care practitioners Identify and correct prescription writing errors Identify and manage inappropriate prescribing and/or polypharmacy Identify opportunities for deprescribing and medicines optimization with patients Assess and manage common ADRs and interactions in the context of the current clinical situation Report a suspected ADR using the MHRA Yellow Card scheme Find and interpret information about adverse drug reactions (e.g. British National Formulary [BNF]) Demonstrate the ability to find and use a Summary of Product Characteristics Demonstrate the ability to use the British National Formulary Demonstrate the ability to find and use Poisons Information Services (e.g. TOXBASE) Interpret national or international guidance (e.g. National Institute for Health and Care Excellence [NICE]) in the context of the care of individual patients Prescribe oxygen safely using appropriate documentation Interpret oxygen saturations and symptoms to guide oxygen therapy Prescribe anticoagulants safely using appropriate documentation Interpret therapeutic drug monitoring where appropriate to guide anticoagulation Prescribe insulin safely using appropriate documentation Interpret blood glucose and other measures where appropriate (e.g. HbA1C, ketones and electrolytes) to guide insulin therapy Prescribe intravenous fluids and electrolytes safely using appropriate documentation Monitor the clinical and biochemical effects of intravenous fluids and electrolytes Prescribe opioid analgesics safely and effectively Convert between one opioid and another, recognizing differences in potency, duration of action and elimination routes Administer drugs by subcutaneous injection Administer drugs by intramuscular injection Administer drugs by intravenous injection Administer drugs by intravenous infusion pumps Administer drugs using an inhaler Administer drugs using a nebulizer Administer drugs to the eye Administer drugs to the ear Administer drugs to the skin Demographics of Delphi participants. IQR, interquartile range. In Round 1 of the Delphi, median agreement for learning outcomes was 81% (interquartile range 76–85%). Thirty‐two learning outcomes (15%) were removed and 59 learning outcomes substantially re‐written or added (28%). In Round 2, 68% of the participants recommended no additional changes. Most changes, where recommendations were made, were of a typographical or grammatical nature. The most significant recommendation in this round was to clarify the meaning of command verbs used in the curriculum and to provide some consistency in use (Table  3 ). This was applied prior to Round 3. There was one area of disagreement among the experts—whether to include ivabradine and nicorandil to the core drugs list (Section II). The expert panels were split evenly on whether to include these drugs or not. The steering committee made the decision to not include these drugs as during the Delphi, agreement had not met the 75% threshold, and the drugs are not highly prescribed from national prescribing data [ 29 ]. In Round 3, there was an agreement on the application of action verbs and some further minor typographical change. There was a debate on the inclusion of Section III, regarding potential duplication of the GMC's content map [ 20 ], with a risk of future misalignment where this was updated. However, most experts favoured its retention, citing its utility in centring early years clinical pharmacology education in disease models and reflecting that the curriculum is likely to have some international utility. Command verbs used in the curriculum. The final curriculum is presented in Table  1 . A full list of all changes to the drug list, alongside a table of changes across other sections of the curriculum, is available in Data  S3 . Briefly, the changes to Section I (Principles of Clinical Pharmacology) were largely with respect to reducing the number of command verbs and clarifying their meanings to better reflect the expectations of a newly graduated doctor (Table  2 ). The number of learning outcomes compared to the last iteration of the curriculum was reduced from 226 to 205. Most changes in Section II (Drugs a ‘Student Formulary’) related to layout or categorization with sub‐headings, including an addition of a topic for ‘emergency drugs’. There were six direct replacements of example drugs (e.g. atorvastatin replacing simvastatin). See Data  S3 for the full list. In Section III (Therapeutics) of the curriculum, many changes involved updating language to reflect contemporary practice (e.g. sepsis from septicaemia). There was also some broadening of topics that relate to primary care (e.g. otitis media). In Section IV, command verbs were again revised in line with other sections. There were eight additional learning outcomes added to this section.

Prescribing a medicine is the most common patient facing health‐care intervention undertaken by doctors, and the process of prescribing a medicine is complex. It requires knowledge of disease and the ability to make a diagnosis, an understanding of therapeutic goals and available treatment options, awareness of potential drug interactions, proficiency in writing prescriptions, and the skills to monitor and adjust therapy as needed. In addition, prescribers must be able to gather and understand the views and beliefs of the person for whom they are prescribing treatment and communicate information about the drug in a way that is clear, accessible and supports shared decision‐making. Doctors must be able to understand their prescribing decisions within the broader context of the population, the health‐care economy, the environment and the evolving landscape of pharmaceutical science. It is perhaps unsurprising that, with many thousands of licensed medicines available to prescribe, errors in prescribing are common. Eight to nine percent of inpatient prescriptions contain at least one error, and doctors earlier in their career are more likely to make errors than those later in their career [ 1 , 2 , 3 ]. Clinical pharmacology education during a medical degree is frequently integrated within systems‐based blocks. Placing the learning of the discipline in a clinical context is advantageous in providing medical students with experience that will mirror their future practice. It does, however, provide educators with the challenge of ensuring that the cross‐discipline elements of clinical pharmacology and therapeutics are covered during the degree [ 4 , 5 , 6 , 7 ]. The British Pharmacological Society aims to provide support for medical schools by outlining a core curriculum in the discipline, the first of which was published in 1997 [ 8 ]. In line with the publication of the 2002 edition of the GMC's Tomorrow's Doctors [ 9 , 10 ], the core curriculum was updated, with a further update in 2011 following recommendations to improve safe prescribing in medical graduates and further changes to Tomorrow's Doctors [ 11 , 12 ]. These British Pharmacological Society curricula have been used to inform the design, development, and evaluation of clinical pharmacology and therapeutics curricula in medical degree programmes nationally and internationally. For example, at Newcastle University, the last iteration of this curriculum was used to design a clinical pharmacology and therapeutics strand [ 13 , 14 , 15 , 16 ]. Other consensus statements on learning outcomes for medical undergraduates have been produced by similar organizations. In 2018, the European Association for Clinical Pharmacology and Therapeutics produced a consensus document utilizing a modified Delphi process to outline key learning outcomes in the discipline [ 14 ]. Unlike the British Pharmacological Society curriculum, this process did not produce agreement on a core drugs list contemporaneously, although this was produced in a subsequent Delphi process [ 15 ]. Other organizations across the globe have produced guidance on undergraduate clinical pharmacology education [ 17 , 18 , 19 ], with a variety of aims and objectives. In our view, none cover knowledge, skills in prescribing and a core list of drugs as comprehensively as the British Pharmacological Society's curriculum, and we can find no updated curricula from the last 5 years. The British Pharmacological Society's core curriculum was designed to provide a guide that could allow medical schools to map clinical pharmacology learning across their degrees and identify where additional learning may be required. The curriculum is divided into four distinct Sections (I–IV) [ 11 ]. Principles of Clinical Pharmacology (Section I) covers learning that broadly might be expected to be learned early in the medical degree to provide a foundation for future clinical application. Drugs (Section II) is a suggestion for a ‘student formulary’—a core list of drugs that a graduating doctor should be familiar with in relative depth. Therapeutics (Section III) provides a list of clinical conditions and their pharmacological treatment essential for a graduating medical student, and Prescribing and Related Skills, reflecting the competencies required of a newly qualified doctor in this domain, are outlined in Section IV. The British Pharmacological Society continues to believe there is value in this resource, which can help to ensure that graduating medical students are ready to prescribe safely, effectively and responsibly. It is also important that doctors are equipped with the skills they will need to continue to learn clinical pharmacology as pharmaceutical science develops throughout their career. In the context of the United Kingdom Medical Licensing Assessment [ 20 ] and the recognition of the importance of clinical pharmacology learning and assessment from the Dacre review [ 21 ], we have undertaken a further update of the content of the clinical pharmacology curriculum using a modified Delphi consensus process. This methodology is recognized for its ability to establish consensus among experts, particularly in educational contexts [ 22 ]. Benefits of electronic Delphi platforms include the ability to disseminate rapidly and widely and afford anonymity to contributors that reduce some of the effects of group dynamic, including bias from power imbalance. Delphi processes have had widespread use in the development of curricula in medical education from a diverse range of specialties, including clinical pharmacology [ 14 , 15 , 23 , 24 , 25 , 26 ].

There is ongoing enthusiasm for guidance on what knowledge doctors of the future need in clinical pharmacology and therapeutics. This is reflective of the consensus among clinicians, medical educators and students themselves that adequate training and assessment in the discipline is likely to improve the quality of care provided by doctors and reduce the risk of prescribing errors [ 21 , 30 ]. The updates to the British Pharmacological Society therapeutics and prescribing curriculum for medical degrees recommended by the participants in the Delphi process represent ongoing evolution of clinical pharmacology and therapeutics as a discipline. We are grateful to all of the contributors to the Delphi process for their time and expertise in this process. Prescribing is a core skill for doctors that must be underpinned by knowledge of therapeutics. The structured learning outcomes enable medical schools to map student learning (and progression) and provide clearly structured and measurable outcomes that align with the needs of clinical practice. We believe this is particularly of use in modern integrated degree programmes. The focus, particularly in Section IV on skills that a graduating doctor requires, aligns with competence and capability‐based frameworks for medical education [ 31 , 32 ]. The curriculum provides support for the increasing interest in personalized medicine. Sections focussing on inter‐individual variability, physiological factors, age and pregnancy provide the foundational principles necessary for personalized prescribing, including integrating pharmacogenomics (PGx) into prescribing education. The utility of electronic tools aimed at assisting prescribers and reducing harm to patients will become an increasingly important part of prescribing education. It is likely that in time this will include explicit educational requirements for understanding how artificial intelligence (AI) may be used as a tool for prescribers. While the challenge of operationalizing this for medical schools is outside of the scope of this work, we do acknowledge it to be significant. Multiple electronic tools are in operation within the UK health‐care sector, and this is likely to expand significantly in the coming decade. How degree programmes adapt to provide appropriate exposure and evaluate competence will need to include building skills to learn and safely adopt new systems throughout a career [ 33 ]. We have been able to gain views from across the spectrum of UK educators, from pre‐clinical medicine to practising doctors and pharmacists. Expertise was provided from a wide range of career stages, including those in their first teaching roles and those who had up to 35 years of experience. The number of contributors is in line with group size recognized to be effective in Delphi processes [ 28 ]. There was institutional representation from Wales, Scotland, Ireland and England. Fourteen of the experts contributing to the Delphi process were clinical pharmacology consultants, representing around 10% of the UK consultant workforce in the specialty [ 34 ]. We believe this is a considerable strength of our work and adds validity to the curriculum in representing an ideal foundation for doctors in the discipline of clinical pharmacology. In our view, this work provides a robust evidence‐informed basis on which medical schools may build their educational material or undertake quality assurance of the delivery of this element of the medical degree in the United Kingdom. The core drugs list has remained broadly similar to the previous iteration. This stability should allow course designers an opportunity to develop long lasting resources that provide students with a ‘good place to start’ in the learning journey about drugs that do not require frequent and extensive revisions. Given the constraints on time for university educators, we believe this is a welcome confirmation of previous work that has established that the most frequently prescribed drugs change little over time [ 35 , 36 ]. This curriculum is consistent with the British Pharmacological Society's principles for inclusive implementation of the undergraduate pharmacology core curriculum, in the sense that the effects of interindividual differences in response to drugs are explored and the curriculum includes how drug effects can be impacted by diet, environmental variation and physiological variables such as age, sex and pregnancy [ 37 ]. While this curriculum does not address how the learning outcomes should be implemented, we encourage consultation with the inclusive principles. The work to update this curriculum has a number of limitations that we would like to highlight. While we are satisfied with the breadth of clinical pharmacology expertise sampled in this process, we acknowledge that the process represents a small sample of the more general medical education community. Alongside this, we did not specifically seek out the views of course leaders or course directors responsible for the delivery and governance of medical courses. Our view is that the Delphi contributors provide a consensus of knowledge from the breadth of a medical degree that comes primarily from their expertise in pharmacology education, the main focus of this work. The recruitment strategy used, which included nomination by those we invited directly, was felt a pragmatic approach to ensure adequate participation and improve inclusivity. The consequence of this strategy is that we are unable to estimate a response rate as one might ordinarily expect from a Delphi report. We acknowledge this limitation, although we are content that the strategy has resulted in a panel with strengths reflected above. We are mindful of the importance of the student voice in curriculum design and implementation and acknowledge that we did not include students in this process. Our focus here was in understanding the core knowledge and skills required of a prescriber, and our view was that this necessitated focus on expertise from educators and prescribers through the Delphi process. We were also mindful of the multiplicity of approaches from degree courses across the UK and the complexity of running a student process within this context. We did include early career resident doctors as contributors. We did not undertake an exhaustive demographic survey of contributors. We note that there were more men (60%) than women (40%) contributing to the process and White/White British ethnicity was most frequently self‐identified. These figures are reflective of the wider UK higher education workforce [ 38 ], and we acknowledge the potential limitations that may derive from this in the process perhaps failing to adequately reflect the populations that are treated by doctors. The expert group was convened through a purposive, invitation‐based recruitment process, relying on invitations being received, disseminated and acted upon. As an endeavour of the British Pharmacological Society, this curriculum is centred in clinical practice in the National Health Service (NHS) and expertise of pharmacologists from the UK, which may limit its transferability to other countries' health‐care systems. There is natural conflict between considering the global perspective and setting out the framework to ensure competence in UK practice—a straightforward example of the kind of question debated in this regard was around the inclusion of anti‐malarial drugs given its importance as a global disease vs . the unlikely event of a newly qualified doctor being tasked with prescribing or monitoring the therapy in the UK. The focus of the experts here was UK practice, and we acknowledge the curriculum reflecting this is a strength for the UK but may limit generalizability. The work retains structure and a reasonable amount of content from the last iteration and so also retains much of the content alignment with the European consensus project and the outcomes are compatible with preparing learners to prescribe in line with approaches described by international guidance, including that from the World Health Organization [ 11 , 14 , 39 ]. Similarly, we are cognisant that there are other professional groups who develop competencies in prescribing and clinical pharmacology. While elements of this work could be used for those professions, direct transfer is unlikely to be possible (or desirable) as the scale and scope of learning will be different when centred in another degree programme. Future work could address some of these shortcomings, including taking the curriculum to patient and student groups for these important perspectives. International collaboration to consider global generalizability of knowledge and skills could also be explored. The curriculum does not provide guidance on delivery of its content as we are of the opinion that individual medical schools are best placed to decide how it could be used in delivering clinical pharmacology and therapeutics learning within their degree. There is no ‘right’ way to teach the discipline and how learning is delivered is beyond the scope of this work, although we refer readers to several recent articles on this topic [ 5 , 6 ]. With many regions lacking expertise from clinical pharmacologists [ 34 ], it is likely that in some medical schools education in this discipline is not necessarily led by a specialist in the field. We therefore view the utility of this curriculum in the UK as providing a supportive framework that could be used to map learning and provide assurance that a medical degree course delivers the required learning. It may also support course design where gaps are identified [ 5 , 6 ]. Similarly, the layout of the curriculum has not been altered from the last iteration. We recognize that there could be a range of ways to lay out the learning outcomes, including mirroring an organ‐based approach that many medical courses divide their learning into. We do not believe there is significant merit of one approach over another and so have restricted debate in this Delphi to the content of learning.

This updated curriculum from the British Pharmacological Society provides a comprehensive and contemporary framework for clinical pharmacology and prescribing education in the UK medical schools. Developed through a rigorous modified Delphi process involving a diverse panel of educators and clinicians, the curriculum reflects the evolving demands of medical practice and the critical importance of safe, effective and evidence‐based prescribing. The curriculum's structured approach, including learning outcomes in pharmacological principles, therapeutics, core drugs and prescribing skills, offers a framework for medical schools to design, map, and quality assure their clinical pharmacology teaching. Its alignment with national assessments and regulatory expectations ensures relevance for both undergraduate education and early clinical practice.

The authors declare no conflicts of interest. RS is an NIHR Research Professor (NIHR303160) and is funded by the NIHR. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

Data S1 List of experts contributing to the Delphi process Data S2 Word cloud of responses to ethnicity from contributors to Delphi process Data S3 Substantive changes to the curriculum following the Delphi process Table S3A. Changes to section 1, Principles of Clinical Pharmacology. In addition to changes in command verbs and some rephrasing, substantial changes are included. Table S3B. Changes to Section II: Drugs (“a Student Formulary”) Table S3C. Learning outcomes added to Section IV: Prescribing and Related Skills