Passing the Prescribing Safety Assessment (PSA)

The PSA is aimed at final year medical students and those graduating overseas to assess their competency at prescribing as Foundation Year 1 Doctors. It can also be taken by Foundation Year 1 doctors if they have not passed it in their final year or had not attempted it before.

Content

It is made up of 8 sections totalling 200 marks. The time given to complete this is 120 minutes. Questions will cover topics such as Medicine, Surgery, General Practice, Psychiatry, Paediatrics, Obstetrics & Gynaecology, and Elderly Care.

The allocation of marks for each section is as detailed below:

  • Prescribing 8 x 10 marks (5 for drug choice, 5 for choice of dose/route/frequency)
  • Prescription review – 8 x 4 marks
  • Planning management 8 x 2 marks
  • Providing information 6 x 2 marks
  • Calculation skills 8 x 2 marks
  • Adverse drug reactions – 8 x 2 marks
  • Drug monitoring 8 x 2 marks
  • Data interpretation 6 x 2 marks

General tips

  • The PSA is a very time-sensitive assessment and therefore time management is important. A guide of how long you should spend on each section (based on weightage) is as detailed below:
    • Prescribing 48 minutes
    • Prescription review – 19 minutes 12 seconds
    • Planning management 9 minutes 36 seconds
    • Providing information 7 minutes 12 seconds
    • Calculation skills – 9 minutes 36 seconds
    • Adverse drug reactions 9 minutes 36 seconds
    • Drug monitoring – 9 minutes 36 seconds
    • Data interpretation – 7 minutes 12 seconds
  • Do all the practice papers and get familiar with using both the online and paper version of the BNF.
  • Use the search function ‘Ctrl + F’ to speed up your searches on the online version of the BNF
  • Be familiar with the “treatment summaries” section in the BNF, as it is not always explicit where relevant information can be found. Some important ones have been listed below.

Screenshot 2021 07 25 163739
Figure 1: Flowchart to keep in mind during the PSA
TopicTreatment summaries title on the BNF
Anxiety/ OCDAntidepressant
Overdose/ DystoniasPoisoning, Emergency treatment
HRTSex-hormones
INROral anticoagulants
Opioid conversionPalliative care
LaxativesConstipation 6
STEMIAcute coronary syndromes
B12 deficiency/ anaemiaMegaloblastic anaemia
Notifiable diseasesAntibacterial
GentamicinAminoglycosides
Excess bleedingAntifibrinolytics
EndocarditisCardiovascular infections
Steroid conversionGlucocorticoid therapy
ShigellaGastro-intestinal system infection, Antibacterial therapy
CholecystitisGall stones
OsteomyelitisMusculoskeletal infection
HeparinsParenteral anticoagulants
Diabetic insipidusPosterior pituitary
Idiopathic thrombocytopenic purpuraPlatelet disorders
PneumoniaRespiratory infections
SmokingSubstance dependence
AntacidsDyspepsia/Chelates and Complexes
Important Treatment Summaries

Components of the PSA

As mentioned before, the PSA includes 8 sections. Listed below are some tips on how to tackle each section

1. Prescribing

There can be a range of scenarios such as treatment of acute conditions (e.g. acute asthma attack, acute heart failure), chronic conditions (e.g. depression, reflux oesophagitis), fluid prescription and important symptoms such as pain.

The approach:

  • Use Figure 1 to help you in this section.
  • For example: ‘What would you prescribed to treat acute pulmonary oedema secondary to left ventricular systolic dysfunction?’
    • The drug of choice that should come to mind is ‘Furosemide” and hence should be searched up on the BNF to get information such as the route, dose and frequency
  • However, if the questions asks “What IV treatment would be prescribed for a hypoglycaemic patient?” and you are unsure about what dextrose preparation to use, seach “hypoglycaemia” on the BNF under treatment summaries. This would then tell you that 10%/20% preparations are preferred over the 50% preparation.
  • If you are unsure about the medication used to treat a condition such as an acute dystonic reaction. The best solution is to search “poisoning” under treatment summaries which would tell you that procyclidine or diazepam can be used in this scenario.
2. Prescription review
  • Typically, the prescription review section involves reviewing 6-10 medications and identifying which medications should be stopped or could be a cause of a clinical problem such as impaired renal function.
  • It can also test on spotting important drug interactions (e.g. verapamil with beta-blockers, erythromycin with warfarin) and identifying dosing errors (e.g weekly dose of bisphosphonates given OD, daily levothyroxine given once weekly).
  • This section can be tight on time and it is not possible to search up every listed medication on the BNF. As such knowledge of common effects, adverse reactions and interactions of common medication is helpful.
  • Refer to the beginning of Appendix 1 in the paper BNF. Over here, there are several tables of ‘drugs that cause…’. This is likely the most efficient method of searching for ADRs when being asked which drug is most likely to cause ‘x’

The approach:

  • If a list of 6-10 medications is given and you were asked to identify 3 medications that would cause confusion, pick the ones you are sure cause confusion and search the ones you think could possible cause confusion on the BNF. Utilise the ‘Ctrl F’ function to speed up your search for the side effect “confusion” when on the medication page.
  • Utilise the “Interaction” section for the medication on the BNF. This will give a list of all interactions with the particular medication you are interested in. Again, use the ‘Ctrl F’ function to speed up your search.
3. Planning management
  • Typically, you will be provided with 5 options and tasked with deciding which treatment would be most appropriate in the management of the given clinical scenario.
  • The treatment is often tailored to individual patients and depends can potentially depend on factors such as gender (e.g duration of UTI treatment for men is 7 days), drug history and allergies.
  • Sometimes it is inappropriate to treat/change management and it important to bear in mind non-drug therapies (e.g. physiotherapy, TENS machines for pain relief) have a role.

The approach:

  • Figure 1 is also helpful in this scenario
  • For example: The question may give you 5 antibiotics as an option and ask you to select the appropriate antibiotic to treat a UTI. If you are unsure of which one to pick, the best thing to do is to search “urinary-tract infections” under treatment summaries, which would tell you the appropriate first and second line treatments.
  • Sometimes different dosages of the same medication are posed as different options in a question so if you are completely sure of the treatment for a condition, the best thing to do is search up the medication on the BNF and select the correct dosage under the indications/dosage section.
4. Communicating information

Typically, you will be provided with 5 pieces of information and tasked with selecting the most important option to provide to the patient. Examples of the medicines that might be the focus of discussion include insulin, warfarin, salbutamol inhaler, methotrexate, or an oral hypoglycaemic medication.

The approach:

  • Search for the medication in question.
  • The information that is important can often be found in “important safety information” ( e.g Rivaroxaban not being effective on an empty stomach ), “patient and carer advice” (e.g advice regarding missed contraceptive doses) or “monitoring requirements”.
  • There is an element of judgement of which is most important, if several pieces of information are accurate.
5. Calculation skills
  • You will be tasked with calculating the dose or rate of administration of a medication.

The approach:

  • Work through calculations of a question twice so as to double check your answers.
  • Be familiar with unit conversions.
Screenshot 2021 07 25 163757
Figure 2: Converting between common units for medications

And preparations: 1% = 1g in 100mL; 1 in 1000 = 1g in 1000mL

6. Adverse drug reactions
  • This section can be structured in a variety of ways, testing either on common adverse drug reactions, potential drug interactions or management of adverse reactions.

The approach:

  • The approach to this is similar to previous sections:
  • Often relevant adverse drug reactions (ADRs) can be found in either the “side effect”, “interactions” or “cautions” section of the medication.
  • If you were interested in finding out whether the combined oral contraceptive pill (COCP) increases blood pressure, use the ‘Ctrl F’ function to search for “blood pressure” on the BNF page for the particular COCP.
  • Sometimes, several drugs may list the relevant ADR in its side-effect profile, you should then pick the drug for which the side-effect is most common.
  • If unsure of how to manage ADR, the answers can often be found in the respective treatment summaries of the BNF. For examples – medication overdoses (poisoning, emergency treatment), hypoglycaemia (hypoglycaemia), reversal of a high INR (oral anticoagulants).
7. Drug monitoring
  • This section will task you with selecting the most suitable plan of monitoring for either beneficial or harmful effects of a newly started medication.
  • It is important to elicit which one of these is being tested as different tests are often required. (e.g., weight is the best monitoring measure for the beneficial effects of furosemide in someone with fluid overload, however, to monitor for harmful effects – renal function)

The approach:

  • Search up the medications “monitoring requirements”, “important safety information” or “pre-treatment screening” on the BNF.
8. Data interpretation
  • You will be provided with a clinical scenario and some investigation results and tasked with determining the most appropriate course of action forward with regard to prescribing. (e.g withdrawing a medication, reducing its dose, no change, increasing its dose or switching to a new medication).

The approach:

  • As the scope of testing for this section can be quite broad, knowledge of some common scenarios will be very helpful:
    • Switch patients not tolerating an ACEi to ARBs
    • Know how to prescribe gentamicin and how to use the gentamicin chart to determine next prescription timing
    • Know how to use the treatment nomogram in paracetamol overdoses.
    • For someone with BD mixed insulin, the morning insulin should be adjusted according to evening BMs and evening insulin adjusted according to morning BMs. (e.g for a patient on Humulin M3 BD, with high morning BMs, evening Humulin M3 should be increased)
    • Oxycodone/fentanyl is preferrable to morphine in impaired renal function

Written by: Dr Nathan Ng (FY2) and Dr Yap Ngee Jin (FY1)
Edited by: Mudassar Khan (Y4 Medical Student)

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