In this WC study, we identified several potential barriers to implementing the European Prescribing Exam. However, participants proposed potential solutions for nearly all these barriers. Nonetheless, it is important to acknowledge that addressing some of these barriers may be challenging and require significant time and effort. The major barriers were related to curricular constraints, motivational challenges, IT infrastructure, and the relevance of the examination. In most countries, curricula are already full and vary widely between institutions, making it difficult to implement a universal examination. Moreover, participants expressed concerns about the language, the time investment, their unfamiliarity with the online system, and the potential impact on medical schools’ reputation if results are published. Despite these concerns, several solutions were proposed. For instance, it was emphasized that the European Prescribing Exam was collaboratively created by clinical pharmacologists from different countries, is based on European consensus studies, and is hosted on a user-friendly online platform. It was suggested that the European Prescribing Exam could initially be used as a formative assessment.

The noted language barrier impacts the foundation of establishing a pan-European examination, as the European Union is characterized by extensive linguistic diversity, with over 20 official languages (e.g., German, French, Spanish). Results from pilot examinations conducted at 16 European universities across 11 countries have shown that language is not a significant barrier. Informal evaluations suggested that students reported that the language did not hinder their understanding or ability to answer the examination questions. These findings support the feasibility of using English as the examination language across different countries. Moreover, advancements in artificial intelligence are making it increasingly easier to translate examination questions accurately in the near future.

Participants also suggested that the final results should not be shared publicly. We noticed a general sense of anxiety among the teachers that students might perform badly on the examination. Many medical schools in Europe still teach their students pharmacology and do not teach them prescribing [20]. The skills part of the European Prescribing Exam focuses on this aspect of CPT and requires students to prescribe for patient cases. We believe the European Prescribing Exam could serve both as a benchmark for proficiency levels that medical graduates should achieve and as a reflective tool for teachers to critically assess their CPT curriculum. The aim is to enable European medical schools to meet the standard of teaching and training in CPT established collaboratively with this examination, not to judge individual schools on their quality.

Another major barrier is that medical curricula are already packed, leaving no room for additional teaching hours or extra examinations. A proposed solution involves using the European Prescribing Exam as a formative assessment, which effectively serves as a first step to convince students, teachers, and curriculum makers of its importance and quality. Formative assessment can also stimulate self-regulated learning by serving as a benchmark for students’ self-reflection [21]. This approach may motivate students to engage more actively in learning and practicing prescribing skills and encourage teachers to adapt the curriculum. Thus, even without a summative component, the European Prescribing Exam has the potential to harmonize CPT teaching and training across Europe. Moreover, in the Netherlands, students recognize the importance of having a dedicated examination on clinical pharmacology, the Dutch National Pharmacotherapy Assessment (DNPA), which facilitates its implementation [22]. If European students also recognize the importance of such an examination, it would facilitate implementation. On the other hand, using the European Prescribing Exam as a formative assessment may also raise questions about its effectiveness. In general, but also in CPT, research shows that scores are lower for formative assessments than for summative assessments because of the lack of (extrinsic) motivation [23, 24]. This was recently confirmed for the DNPA, where scores were significantly higher in medical schools with either a summative or programmatic assessment program rather than a formative assessment program [25]. Programmatic assessment led to a modest decline in scores compared to summative assessment. Therefore, one could argue that the European Prescribing Exam should be incorporated as at least a data point in a programmatic assessment program, with the ultimate goal of implementing it as a summative assessment. On the other hand, incorporating a formative examination, including feedback on provided right and wrong answers in a programmatic assessment curriculum, could well increase the prescribing skills of students without a score.

The IT infrastructure supporting the examination also presents a potential barrier, particularly regarding the unfamiliarity of both teachers and students with the Moodle platform that hosts the European Prescribing Exam. A major advantage is that the Moodle system is accessible on any electronic device with internet access and features an intuitive interface. The Erasmus + project “Clinical Pharmacology and Therapeutics Teach the Teacher (CP4T)” program will organize an online workshop for teachers to improve relevant IT skills. Moreover, Moodle has sufficient database capacity to store all examination questions, addressing one of the potential barriers for which no solution had previously been suggested.

Some barriers were not identified during the WC but were proposed by the authors themselves. One such concern is the sustainability of the European Prescribing Exam, as it was initially funded by an Erasmus + grant that ended in 2023. Currently, the Education Working Group of the EACPT oversees the organization of the exam. Participating medical schools contribute by actively engaging in the development, review, and updating of exam questions.

From a political perspective, concerns may also arise regarding data protection and the security of cloud-based systems. To address this, the European Prescribing Exam is hosted on a European server, and official legal agreements are in place between participating medical schools, the hosting provider, and an intermediary organization.

This is the first study to investigate potential barriers and solutions for implementing a pan-European examination, as proposed by CPT teachers. The WC method is particularly suitable to investigate this, as it fosters large group discussions and actively involves all participants. Moreover, it aims to find solutions for specific problems or barriers. Also, participants come into contact with their peers and can use the suggested solutions directly after the session. Moreover, this is the first study to explore the potential barriers and solutions for implementing a pan-European examination. Similar examinations have been developed by the European Union of Medical Specialists and the British Pharmacological Society and UK Medical Schools Council (the Prescribing Safety Assessment), but, to our knowledge, these were not evaluated with this method [26, 27]. Nevertheless, some limitations should be taken into consideration when interpreting the results of this study. First, only participants who attended the 2-day event about the European Prescribing Exam participated in this study. This could have biased the results because all participants were intrinsically motivated to implement the examination. On the other hand, this led to positive discussions, and it was a large group of relevant coordinators in CPT education across Europe. Second, besides being notetakers, students did not actively participate in this study, even though they are important stakeholders in examinations. This might have led to missing important barriers and solutions. Third, the project team identified the five topics in advance, so there was no room to discuss other aspects. Moreover, participants might interpret the five topics differently. However, at the start of each round, the moderator introduced the topic, and during the general discussion afterwards, no one added new topics. Fourth, the session was not recorded, so the analysis was only based on the sticky notes, flip-overs, and the interpretation of the moderators and the notetakers afterwards.

On the basis of findings, we make recommendations for both teachers and the future organization of the European Prescribing Exam. For teachers, (1) as (sometimes) with prescribing, start low and go slow. Curriculum adjustments are challenging and take time. Therefore, we recommend introducing the European Prescribing Exam gradually, initially as a formative examination, and then explore further possibilities. (2) Join the working group for the European Prescribing Exam to ensure the content is relevant to and applicable for your own country. (3) Show both students and curriculum makers the importance of a dedicated examination on CPT that assesses both knowledge and skills to enhance their (intrinsic) motivation. For the future organization, (1) each participating country should appoint a representative to advocate that country’s interests. (2) Each university should contribute to the development of examination questions to ensure broad coverage. (3) Courses should be organized on how the system works and how to manage it effectively. (4) To ensure that the European Prescribing Exam continues to function and evolve in the long term, its sustainability must be regularly reviewed.