Knowledge, Attitude and Perception of Medical Students regarding Deprescribing in Lahore, Pakistan

Figure 1. (a) Cellular-level disease complexity; (b) Clinical imaging illustrating disease burden. Such conditions often require long-term pharmacotherapy, increasing the risk of polypharmacy and the need for deprescribing.

Polypharmacy is defined as “the use of multiple medications, is recognized as a risk factor for adverse drug reactions and healthcare utilization among older adults”(Aggarwal, Woolford, & Patel, 2020; Lund, Carnahan, Egge, Chrischilles, & Kaboli, 2010; Wastesson, Morin, Tan, & Johnell, 2018). As the percentage of the population over the age of 65 continues to grow, the demand for healthcare professionals trained to care for this demographic will also increase (Wu et al., 2010). Older age is linked to a higher risk of developing multiple long-term conditions. Multi-morbidity and polypharmacy contribute to a gradual decline in resilience and impaired homeostasis, leading to a substantial health and social care burden (Aggarwal et al., 2020). The knowledge translation definition by the Canadian Institutes of Health Research as "a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system. " This definition has been incorporated by others including the United States National Center for Dissemination of Disability Research and the World Health Organization (WHO) (Straus, Tetroe, & Graham, 2009).

Since physicians are primarily responsible for prescribing and monitoring drug therapy, their perception of deprescribing and knowledge of available deprescribing tools is crucial (Akande-Sholabi, Ajilore, & Ilori, 2023). Deprescribing is a complex task that involves clinical expertise, shared decision-making with patients and caregivers, and effective communication among all care providers.

The knowledge translation definition by the Canadian Institutes of Health Research as "a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system. " This definition has been Incorporated by others including the United States National Center for Dissemination of Disability Research and the World Health Organization (WHO) (Straus, Tetroe, & Graham, 2009). Since physicians are primarily responsible for prescribing and monitoring drug therapy, their perception of deprescribing and knowledge of available deprescribing tools is crucial (Akande-Sholabi, Ajilore, & Ilori, 2023). Deprescribing is a complex task that involves clinical expertise, shared decision-making with patients and caregivers, and effective communication among all care providers.

In the United States, the entry-level degree required to practice pharmacy is the Doctor of Pharmacy (Pharm-D). In addition to medication distribution, pharmacists regularly work in clinical roles, collaborating with medical providers to optimize medication therapies. Recent studies have highlighted the value of pharmacists in facilitating deprescribing throughout the continuum of care (Martin, Tamblyn, Benedetti, Ahmed, & Tannenbaum, 2018). Older adults are living longer and using more medications. Adverse drug reactions (ADRs) are considered one of the top five major health risks for this population. Prescribing medications with known ADR risks to older adults has been associated with increased healthcare utilization and mortality. Identifying and minimizing the use of medications that pose more risks than benefits in older adults is crucial (Ammerman, Simpkins, Warman, & Downs, 2019).

Defining attitude with reference to psychology “a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor” (Eagly & Chaiken, 1993, p. 1). Attitudesnamely, tendency, entity (or attitude object), and evaluation is the important features of this definition (Eagly & Chaiken, 2007). Deprescribing should be regarded as an essential aspect of good prescribing and viewed by physicians in the same light as prescribing or continuing a medication, considering both the potential benefits and harms. In general, deprescribing is a complex process that requires clinical expertise, shared decision- making with patients and caregivers, and effective communication among all healthcare providers (Al Omari et al., 2023)Definition of perception by Longman Dictionary of Contemporary English is“a) the way you think about something and your idea of what it is like;b) the way that you notice things with your senses of sight, hearing etc.; c) the natural ability to understand or notice things quickly“ (Agbor Njang-Tyson, 2023). In philosophy, psychology, and cognitive science, perception is the process of having awareness or understanding of sensory information. . “perception” is the Latin words perception, percipio, and means “receiving, collecting, action of taking possession, and apprehension with the mind or senses (Bai, 2001).

Deprescribing has emerged as a crucial skill for healthcare professionals. Pharmacists are particularly well positioned to identify medications that should be discontinued, such as those with no clear indication or benefit, intolerable adverse effects, or known risks due to drug- drug or drug-disease interactions (Al Omari et al., 2023). This study initially explored whether students were taught about deprescribing and the methods through which it was taught, such as through lectures, case studies, or hands-on experience. It then examined the student’s perceptions of their pharmacy school’s curriculum regarding deprescribing, their views on patients' ready to undergo deprescribing, and the barriers they identified in implementing deprescribing.

The study assessed the students' attitudes, knowledge and perception toward deprescribing, their self-reported abilities, and their confidence levels in carrying out deprescribing practices. Finally, the research compared students who had received training in deprescribing as part of their curriculum with those who had not, focusing on differences in their perceptions of the curriculum, patient willingness to deprescribe, perceived hurdles, and their own attitudes, skills, and confidence in the practice of deprescribing. With the rising prevalence of polypharmacy, deprescribing has become an essential aspect of patient-centered care, particularly in managing multi- morbidity and minimizing medication-related harm.

The need for deprescribing education in health professions curricula is well established, as it equips future healthcare professionals with the skills to optimize medication use. Increasing emphasis on interprofessional simulations and structured educational interventions aligns with existing recommendations, highlighting the necessity for institutions to integrate deprescribing training into medical education (Cernasev et al., 2024). This research is as it adds to existing literature by providing insights into how deprescribing is incorporated into medical education and the impact of this instruction on students' readiness to apply deprescribing practices in real- world settings.

1.1.  Ethical Consideration

This study was approved by the ethical committee of Akhtar Saeed College of Pharmaceutical Sciences. Before conducting the research, informed consent was also obtained from each participant. Research ethics were also considered, as no misleading information was employed as the basis for the study.

1.2.  Study Design

A cross-sectional survey was carried out from January 2025 to June 2025. Individuals residing in Lahore, Pakistan were included in the study. The sample was divided into five groups of medical students of their respected discipline (Bachelor of Medicine, Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS), Doctor of Pharmacy (Pharm.D), Doctor of Physical Therapy (DPT), or Nursing).

1.3.  Study Population

The research included a total of participants (n=281). Incomplete forms were excluded while evaluating results.

a.       Inclusion Criteria

This study includes all individuals who were interested in being part of this research Participants eligible for inclusion in this study were required to be enrolled in a recognized healthcare-related degree program, including Bachelor of Medicine, Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS), Doctor of Pharmacy (Pharm.D), Doctor of Physical Therapy (DPT), or Nursing. To ensure consistency in academic experience and training, only students admitted during the academic years 2020, 2021, or 2022 were considered. Furthermore, only those who had fully completed the survey form were included, ensuring the reliability and completeness of the collected data for analysis.

b.        Exclusion Criteria

This study excludes those individuals who are not willing to participate in the study, and Participants were excluded from the study if they were not enrolled in one of the specified healthcare-related degree programs (MBBS, BDS, Pharm.D, DPT, or Nursing) or if their enrollment year fell outside the academic years 2020, 2021, or 2022. Additionally, individuals who submitted incomplete or partially filled survey forms were excluded to maintain the accuracy and completeness of the collected data.

1.4.   Procedure

Participants were drawn randomly from various social media platforms. Before the initiation of the survey, the participants were given a full explanation regarding the purpose of this research, and their consent to participate in the study was obtained. The questionnaire was in English language and was developed as a soft copy using Google form and distributed via electronically to the participants taking part in the research. The filled questionnaires were collected at a suitable time indicated by respondents.

1.5.   Sample Size

Raosoft scale was used to calculate the sample size, yielding a sample size of participants for the study. Considering an error of % in mnd to get a minimal response ratio a total of sample size was the final number of responses required for data collection.

2.6. Questionnaire Development

The systematic creation of a questionnaire relied on extensive literature research for assessing medical students' deprescribing-related knowledge and attitudes together with their opinions. The survey designers carefully included relevant factors which might impact student comprehension levels and deprescribing practice.

1. Basic Data about Study Participants

Demographics which included age, gender, current year of study, academic concentration, public or private educational setting and past experience in elderly patient care were recorded

during the first phase of their questionnaire. Deprescribing-related opinions and feelings of students are substantially impacted by their demographic traits according to research. Medical schools shared data to obtain an extensive assessment of their students.

2. Knowledge Regarding Deprescribing

This part of the questionnaire evaluated student understanding of deprescribing processes and fundamental principles by providing them closed-ended response options. One of the questions concerned older person medication appropriateness while other questions addressed suitable replacements for discontinued medications and deprescribing strategies. A five-item Likert scale containing strongly disagree, disagree, neutral, agree, and highly agree responses enabled a more detailed evaluation of student knowledge about deprescribing methods and their confidence applying these procedures.

3. Attitudes Towards Deprescribing

The assessment of deprescribing attitudes used several statements presented through a Likert rating scale. This section aimed at evaluating the perspectives of medical students regarding deprescribing practice and their preparedness to perform it while identifying obstacles they might encounter. The survey assessed participant opinions regarding the appropriateness of deprescribing medications that have ambiguous indications and complex dosages and the drugs patients want to discontinue.

4. Perception of Deprescribing Practices

An established set of closed-ended questions was designed to help understand how medical students perceive the deprescribing process. This part concentrated on surveying students about the responsibilities of healthcare providers in deprescribing (prescribers, pharmacists, and nurses) together with the (weights given to patient education and the necessity of team collaboration for successful deprescribing approaches.

5. Barriers to Effective Deprescribing

The section evaluated medical students' viewpoints regarding predicted deprescribing process barriers. The validated instrument consisted of ten questions which examined medical students' deprescribing barriers stemming from their concerns for withdrawal symptoms and their insufficient training and inadequate healthcare system assistance as well as patient adherence challenges. Each participant had the chance to select potential barriers that could impede effective deprescribing by using a self-administered format that included response options.

2.7. Data Analysis

In order to determine the connections between students' knowledge, attitudes, perceptions, and demographic factors, statistical software (such as SPSS) was used to evaluate the data gathered from the completed questionnaires.

2.7.1.                       Method of Data Collection

We developed a questionnaire on Google Forms that assess participants’ attitude, perception, and knowledge related to Deprescribing. Data was collected through an online survey using Google form that was shared with participants through email, social media, or websites and their responses were automatically collected and stored in spreadsheet.

2.7.2.         Statistical Analysis Tools

Data analysis was accompanied using Statistical tools. Statistical Package for Social Sciences (IBM SPSS, version 26.0), has been used for analysis of the collected data.

A total of 281 students took part in the study, the majority of them were women (63%), 48% of the participants were in their final year, and the majority (71.2%) were from private institutions. Additionally, 59.4% had previous experience for providing care to senior citizens. Most participants (81.1%) were students.

Table 1. Sociodemographic Characteristics of Participants

About half of the participants (50.5%) reported being familiar with the term "medication review” in table 2. Additionally, 34.2% believed that deprescribing instruction is a necessary part of the curriculum. Lectures were the most commonly cited method for delivering deprescribing education (36.7%). Notably, 6.8% of participants indicated that their institution did not cover deprescribing at all. The majority (70.8%) believed that prescribers should be responsible for deprescribing.

Table 2. Participant’s familiarity and exposure to Deprescribing and related terms within their university curriculum

In general, participants showed an admirable attitude toward deprescribing in table 3. Most subjects agreed that thinking about removing drugs from prescription is not appropriate (42%), also taking out drugs written without a clear indication (52%), or drugs that are unlikely to help a patient in their remaining years (44.8%). Similar to this, participants expressed interest to consider deprescribing medications with complicated dosing schedules (43.4%), with delayed benefits (44.5%), and based on patient preferences (46.3%).

Table 3. Participants attitude towards deprescribing

In table 4 majority of participants strongly agreed (40.9%) that it is important to ask about patient knowledge and medication use before deprescribing. For other statements, the majority selected agree as their response: 51.2% agreed on reviewing risks and benefits, 45.6% on checking medications against clinical guidelines, and 48.8% on reviewing clinical information such as interactions, adverse drug reactions, and allergies. Similarly, 42% agreed on the need to collaborate with primary care physicians, 44.1% on recommending alternative treatments, 45.6% on planning a tapering schedule for medications with withdrawal risks, and 45.9% on educating the patient after physician approval.

Table 4. Medical Students’ perception towards deprescribing

/The results from table 5 shows limited level of knowledge among participants regarding deprescribing. 38.8% of participants indicated that acetaminophen was not targeted for deprescribing. Only 14.9% reported there was no acceptable alternative to zolpidem. Paroxetine was identified as inappropriate due to its anticholinergic activity by 21.4% of respondents. The correct deprescribing strategy for alprazolam was selected by 37.4%, just 6% select the need to taper omeprazole after ICU discharge. In the last, 28.1% pick the rationale for the antipsychotic black box warning.

This study included 281 medical students from public and private institutions in Lahore, Pakistan, enrolled in MBBS, BDS, Pharm.D, DPT, or Nursing programs. Only students admitted in the academic years 2020, 2021, or 2022 were eligible. In this study we explored how future healthcare professionals understand and approach deprescribing a important process for optimizing medication use, especially in elderly patients with polypharmacy. The objective was to assess whether students from different healthcare disciplines possess the necessary knowledge, attitudes, and perceptions for deprescribing. We hypothesized that medical and pharmacy students would have greater understanding in deprescribing, but only if they had received education on the topic within their curriculum.

The findings show the insights into student familiarity regarding deprescribing. (40.2%) of participants were familiar with the term “deprescribing,” and 34.2% reported it as a required part of their curriculum. Lectures and hospital training were the most common modes of exposure. This shows student have limited practical involvement. As hypothesized, students from medical (MBBS) and pharmacy (Pharm.D) backgrounds, who are more likely to learn about deprescribing in a proper class, showed relatively higher awareness and confidence. This match with previous literature, such as (Clark et al., 2020) and (Al Omari et al., 2023), which found that curricular exposure directly influences students’ knowledge and attitudes. This study also showed that the prescribers and pharmacists as primarily responsible for deprescribing, which supports interprofessional collaboration models seen in international studies. However, the overall low scores in specific knowledge-based questions highlight a gap between theoretical understanding and clinical application (Clark et al., 2020). These findings align with global research showing that, even with positive attitudes, healthcare students often lack the knowledge and practicality for deprescribing without training.

When compared with recent literature, the findings of this study is similar with previous research conducted among healthcare students. A 2023 study by (Al Omari et al., 2023) found that pharmacy students in Jordan had positive attitudes toward deprescribing but find gaps in knowledge and confidence, which we also find in this study. Similarly, (Akande- Sholabi et al., 2023) highlighted that physicians' understanding of deprescribing was Insufficient without formal training and this support our hypothesis that curricular inclusion improves competence. (Scott, Cernasev, Barenie, Springer, & Axon, 2023) also reported that structured deprescribing education play important role in enhances students’ readiness to deprescribe and impart good impact on interprofessional collaboration. So, this study reinforces the need to add deprescribing into medical and pharmacy curricula to close the gap between knowledge and practice.

Study shows useful information about how good medical students understand deprescribing. It shows that while many students have a positive attitude, their knowledge and practical skills are not strong unless they are taught about deprescribing in their courses. Many students believed deprescribing is mainly the responsibility of prescribers and pharmacists and agreed that working in teams, reviewing clinical information, and educating patients are important steps. This shows they have a good overall perception of deprescribing. Adding proper deprescribing education in medical and pharmacy programs can help future healthcare workers to make better decisions, reduce unnecessary medicines, and improve patient safety.

Although students from different healthcare fields took part, the study had some limits. It was done only in Lahore, included no follow-up, and used a one-time survey. These problems are also seen in similar recent studies. To improve future research, students from other provinces and more types of colleges should be included.

This study demonstrates that medical students from different fields in Lahore have a mostly positive attitude and perception toward deprescribing. However, many of them lack strong knowledge and are not fully prepared to use deprescribing in clinical settings. Only a few students were familiar with key deprescribing ideas or had been properly taught about it in their classes. Many students’ response that doctors and pharmacists play a key role in deprescribing. But their low scores in knowledge questions suggest that without proper teaching and training, students may find it hard to use deprescribing in real situations. These results show that deprescribing should be teach in medical and pharmacy education through lectures, case studies, practice sessions, and teamwork activities. Helping students learn and feel confident about deprescribing will prepare them to handle polypharmacy especially in older patients and focus more on patient care, and make better decisions. Future research should include students from other areas and follow up over time to see the effects of deprescribing education.

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