Self-perceived Preparedness to Prescribe Antibiotics Among Swiss Medical Students: Results from a Cross-sectional Survey in four Swiss Universities in 2015.

Background Previous studies have highlighted that medical students do not feel well prepared to prescribe antimicrobials. The ESCMID Study Group for Antimicrobial stewardshiP (ESGAP) conducted a survey among European medical students to assess self-reported preparedness about prudent antibiotic use and the perceived lack of education. The aim of the present study was to specically focus on the perceptions of Swiss medical students. A cross-sectional web-based survey was conducted in 2015 by ESGAP involving sixth-year medical students from Switzerland. The survey investigated self-reported preparedness on diagnosis and treatment of infections, availability and perceived usefulness of different teaching methods and the perceived need for further education on antibiotic use. “Preparedness scores” were created by calculating the percentage of students who felt suciently prepared on each topic.


Background
Antibiotic misuse is frequent and a key driver of antimicrobial resistance (AMR) [1,2]. Educating future prescribers in the appropriate use of antimicrobials early during medical studies seems a key intervention for improving antibiotic use in the medium and long term [3][4][5]. Undergraduate curricula usually include learning objectives regarding the diagnosis and treatment of infections and increasingly highlight also the risk of misuse of antimicrobials and the global concern of increasing AMR [3,6]. Despite these efforts, previous studies have shown that medical students do not feel well prepared to appropriately prescribe antimicrobials at the end of their studies [7][8][9][10].

The ESCMID (European Society of Clinical Microbiology and Infectious Diseases) Study Group on
Antimicrobial stewardshiP (ESGAP) conducted a cross-sectional web survey among nal year medical students from 29 European countries, including Switzerland, in 2015, which has recently been published [11]. This Student-PREPARE survey investigated self-reported preparedness on different topics about prudent antibiotic use and the perceived lack of education, and compared the results among the participating countries. Although some differences emerged across countries, most European students expressed a need for more education on antibiotic use [6,11,12]. In this manuscript we present an in-depth subgroup-analysis of the Swiss results of the survey.

Swiss medical school system
The program of Swiss medical schools is regulated by Federal law [13]. During the Master studies, the majority of learning activities take place in hospitals. In the nal year, students complete 10 months of clinical internships in different settings. At the end of the sixth year, students take the Swiss Federal Examination in Medicine, in order to continue their training as junior doctors at hospitals.

Study design and participants
This study was part of the ESGAP Student-PREPARE project, a cross-sectional multicentre web-based survey conducted in 2015 which aimed to assess nal year medical students' self-reported preparedness on prudent antibiotic use, the results of which were published in 2018 [11]. Twenty-nine European countries [EU Member States together with the four European Free Trade Association countries (Iceland, Liechtenstein, Norway and Switzerland)] were involved in the study. In each country a local coordinator invited all medical students in their nal year to participate, as previously described [11]. The survey was self-administered and was accessible on Survey-Monkey© from January to December 2015. Here, we report the subset of data collected among Swiss medical students.

Questionnaire development
The questionnaire was designed by international experts on antimicrobial stewardship and was informed by previous studies conducted among medical students [7,10,14]. The survey was composed of 47 items divided in 3 sections and was administered in English. The rst section included questions on demographics. The second section assessed self-reported preparedness on 27 topics related to diagnosis and treatment of infections and prudent use of antibiotics; these questions were formulated using a 7-point Likert-type scale. The last section focused on availability and perceived usefulness of different teaching methods and the perceived need for further education.

Statistical analyses
The survey results were analysed using Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA, USA). Categorical variables are presented as percentages.
Responses to questions on preparedness topics were merged in 2 categories (1-3, not su ciently prepared; 4-7, at least su ciently prepared). For each curriculum topic, a "preparedness score" was created by calculating the percentage of students who felt at least su ciently prepared on each topic at medical school level. A national preparedness score for each topic was then calculated as the mean of the different medical school preparedness. A global preparedness score was calculated for each student as the percentage of topics on which the student felt at least su ciently prepared. A medical school global preparedness score was then calculated as the mean of the student's preparedness score and nally a national preparedness score as the mean of the schools' preparedness scores.  Conversely, lower preparedness rates emerged in the sections where "prescription" skills were investigated.
More than half of the students (66.9%) felt su ciently prepared to prescribe an antimicrobial treatment according to guidelines (La: 73.2%, Be: 70.6%, Ge: 68.2% and Zu: 56.4%), but this rate was lower when students were asked to prescribe without using guidelines (33.8%); Lausanne was the only school where at least half of the students (51.2%) reported that they felt su ciently prepared for this task (Ge: 36.4%, Zu: 25.6% and Be: 20.6%).

Discussion
This study shows that, as their European colleagues, Swiss students do not feel su ciently prepared on antibiotic prescribing and they feel they need more education. Although the preparedness scores of Swiss students largely overlap with the European results, some differences can be highlighted.
The proportion of Swiss students who felt prepared to prescribe a treatment without using guidelines was much lower than that reported across Europe and, looking in detail, this was reported by all the universities but Lausanne. On the other hand, the rate of students feeling prepared to select a treatment according to guidelines was similar to European average. A similar pattern had emerged for UK students, suggesting the hypothesis that large availability of local guidelines may be helpful, especially for young physicians, but could lead to the feeling of not being capable to prescribe a treatment independently [11]. As guidelines will never be able to cover all possible clinical situations that prescribers face in real life practice, educators should pay particular attention to help students developing the skill to judge the applicability of guidelines.
Preparedness on use of point-of-care test was higher for Swiss students, but, as well as prescribing according to guidelines, this was one of the topics with the greatest variation in preparedness among countries, related to different availability of resources and variability in national recommendations [11].
Swiss students reported high scores of preparedness in diagnostic issues, as had their European colleagues involved in the Student-PREPARE survey and in previous studies [9][10][11]15]. However, misdiagnosis is one of the main reasons for unnecessary antimicrobial prescriptions, as well as misinterpretation of clinical or microbiological data [2]. Therefore, this self-con dence might be at least partially biased by some lack of "real life" clinical practice experience and failure to appreciate the "swampy lowlands" of medical decision making with real patients that do not t textbook descriptions [16].
In the Student-PREPARE survey, higher levels of preparedness were consistently reported in some countries.
Possible explanations for these ndings include a difference in the quality of education provided in different countries, but also cultural factors related to self-con dence and preparedness feeling [6,11,17]. Cultural differences between French speaking and German speaking regions in Switzerland have been pointed out as one of the factors in uencing the disparities regarding use of antibiotics and rates of antimicrobial resistance among Swiss cantons [18][19][20]. Although we observed some differences in the preparedness for some topics and in the availability of teaching methods among universities, we did not observe a correlation in strengths and weaknesses when comparing French (Geneva and Lausanne) and German speaking faculties (Berne and Zurich).
Swiss students, as well as their colleagues from other countries and disciplines [11,21], stressed the importance of active methods of learning, as well as their inadequate availability. Infectious disease internships, whose effectiveness in improving knowledge and con dence in AMS principles has been shown in different studies, should be encouraged and made possible for every student [21][22][23].
As suggested by King et al., some of the skills where students report the lower preparedness, which involve more complex antimicrobial stewardship (AMS) strategies, could be more di cult to address with traditional teaching methods, leading to the need of frequent re-evaluation of both teaching contents and their delivery methods [21,24]. Only half of the Swiss students (as well as the Europeans) reported feeling prepared to work in a multidisciplinary team, suggesting the need to move towards interprofessional educational strategies [21,25]. Workshops where pharmacy and medical students collaborate dealing with clinical case simulations have been shown to help both in conveying AMS concepts and in highlighting the importance of interprofessional collaboration [25]. Promoting interaction among different health care professions, by inviting pharmacists, dentists, nurses and midwives to participate in lectures where AMS concepts are taught to medical students, could set up the basis for cooperation.
The validity of our results may be partially limited by the low response rate, but this was similar to response rates obtained across Europe and to those reported by previous similar studies [8,10,11].
Nevertheless, as previously published, the low response rate does not necessarily undermine the study's representativeness [26,27]. Due to the small number of respondents, differences in responses between the different universities should be interpreted with caution. A larger participation could help to better understand possible gaps in the education program, as well as differences among Swiss universities, in order to de ne targets that need to be improved. Furthermore, the responses are self-reported and therefore do not necessarily re ect the objective "real degree" of preparedness or real practices with patients.
Since 2015 Switzerland has adopted a national strategy on antibiotic resistance [28]. Improved education of medical students is currently not a core component of the strategy. In 2019 ESCMID published a set of generic competencies in antimicrobial prescribing and stewardship relevant to every independent prescriber. Educators could bene t from this list to guide the revision of curricula and teaching materials [29]. More active and interprofessional teaching activities seem like an essential step to guarantee that future physicians will use antibiotics more responsibly than the preceding generations.

Conclusions
Most Swiss nal year medical students feel they need more education on antibiotics or at least on their prudent use. Some of the teaching methods perceived as more useful by students, such as discussion of clinical cases or infectious diseases clinical placement, seem still insu ciently available in most Swiss medical schools. Active and interprofessional teaching activities, involving pharmacists, nurses and other health professions, can be a rst step towards more effective education on prudent antibiotic use.

Figure 1
Perceived usefulness of teaching methods in Swiss Universities.