Pharmacists as prescribers of medication
I was reading on Kevin, MD the other day a post about pharmacists "wanting" to prescribe. The article was about Canada, but we're rapidly moving in that direction here in the United States as well, with the PharmD degree being the only one that's offered.
This article is pretty long, so you may wish to get a cup of coffee or something before you read it, but I do think it's very relevant to healthcare today. The sections:
- The retail misconception
- Healthcare as a collaboration
- A problem of medical records?
- Making a diagnosis vs determining treatment options
- Pharmacists are already prescribing today
- Who's more qualified?
- Random talking points
- Conclusions
There was quite a bit of excited discussion in the thread, and I wanted to address some of those things here. Some were legitimate concerns, and some were just plain wrong. I have mixed feelings about being able to prescribe someone medication. On the one hand, it would be terribly convenient to alter drug therapy when the prescriber can't be reached, but on the other hand, that's quite a bit of additional responsibility. (Not from a "getting work done" point of view, but rather being directly responsible for therapeutic outcomes.)
In my experience dealing with most pharmacists and most pharmacy students, most of them chose the path because it paid well, was relatively stress-free,* and while it was challenging to make it through, the financial and personal rewards at the end made it worth it. Not because they're necessarily passionate about being a pharmacist. Naturally, there are exceptions to these rules — such as yours truly; I truly love medicine in general and pharmacy in particular — and this phenomenon isn't even a bad thing. There's nothing wrong with not being passionate about what you do. (Though I do think that actively disliking one's job is a recipe for disaster, particularly if you are a pharmacist.)
One of the reasons for this lack of passion is that being a pharmacist is largely a passive role in healthcare. The most exciting and interesting parts of my day are the discussions I have with patients about XYZ. Those are the moments that make what I do truly worthwhile. I think a more active role in healthcare would cause a lot of pharmacists to be happier about their jobs. Not that I think that job satisfaction should be a reason to involve pharmacists more actively — rather, I think that involving pharmacists more would results in more positive therapeutic outcomes if for no other reason than they are more accessible than any other provider.
* Where stress-free is defined as work stays at work when you leave, not that working in a retail environment is without stress, because this is most certainly not the case.
The retail misconception
First off, not all pharmacists are retail pharmacists. That is, of course, what everyone thinks of when they think of a pharmacist, but the majority of RPhs out there don't stand behind a counter all day and count pills. They do other things. When we're talking about pharmacists prescribing meds, we're not necessarily talking about your neighborhood pharmacist. That's probably the biggest misconception out there — even among other healthcare providers.
Discussion-based healthcare
Medicine is slowly but surely moving towards a more collaborative style of managing outcomes. This stems from the fact that breakthroughs occur faster than any one person can keep up with, which in turn results in specialization. Everyone in healthcare knows this intuitively, even if they perhaps haven't sat down and thought about it in such explicit terms.
In many cases, pharmacists — especially clinical pharmacists specializing in something, e.g. geriatrics — knows more than your average GP when it comes to dosing and drug interactions in general in their field of study. This is often why you'll find pharmacists supervising physicians in managed care settings like nursing homes. In their field, they're quite simply better at making the right decision because they know more about that particular aspect of patient care. I can think of two different clinical pharmacists who regularly sit down and work out the pharmacokinetics for drug regimens for specific trouble patients. These two people are incredibly well respected, and when they make a treatment suggestion, it is always followed. (And I'm not aware of a single case where they've been wrong.)
This is the collaboration I'm talking about. Mostly it applies to difficult patients: those on lots of meds or who have idiopathic symptoms — which are often the result of drug therapies unsuitable for those with impaired liver and renal function. Being able to tweak these meds without having to call for a doctor's authorization would be wonderful (and is wonderful in the settings where it occurs).
Ever tried to call a doc's office and get a response within a reasonable amount of time (20-30 minutes)? Hah! It rarely happens. Naturally this is because docs are incredibly strapped for time, and I sympathize, but it does make getting an approval immensely frustrating. It's also frustrating for the patient, which is why pharmacists are consistently considered the most accessible healthcare experts in the field. These are all problems the medical profession knows about, and I think it will eventually get better.
And pharmacists are going to keep medical records where? And how are they going to prevent duplications?
There are three problems with this argument.
1) More than 50% of our patients (especially the elderly) see more than one doctor. You think they're sharing medical records in perfect accord? Well, I can assure you they probably aren't. I've seen quite a few drug interactions because Doc A doesn't know what Doc B is doing. Trusting a patient to facilitate conversation between the two providers is nothing short of laughable in most cases.
2) The other problem with this argument is that most patients go to the same pharmacy all the time, regardless of who the doc writing the script is, which puts the pharmacist in a unique position. I don't know what is meant by duplication, but if that person is referring to getting the same drug twice, the insurer simply won't allow it. Ironically, this means that insurers are helpful in tracking down therapeutic duplications, even if a patient doesn't go to the same pharmacy all the time. Insurance rejections are, of course, an imperfect solution, but most people have some form of third-party coverage, whether it's a discount or actual insurance.
3) Because of point #2, pharmacists are better able to see the overall picture from a therapeutic standpoint than Doc A or Doc B alone. If they can't see it directly, they can respond indirectly to an insurance rejection, for instance, and dig deeper to see what's going on.
I've written extensively on universal access to healthcare records before (not on this site), and this would solve a lot of these problems. However, this is years away. As universal access improves, we'll be seeing more of this active collaboration, rather than providers all working in their own little vacuums.
Making a diagnosis vs determining treatment options
I wouldn't trust a pharmacist to know the difference between peritonsillar abscess, viral URI and Lemierre's syndrome. These would all be treated the same by the pharmacist (no disrespect to them). If someone isn't trained to do something, why would they want to perform that task?
In most cases, pharmacists don't want to make diagnoses, so this point is completely irrelevant, and demonstrates a misunderstanding of the difference between the roles of doctor and pharmacist. Every pharmacist I've talked to knows they're not well-equipped to make complicated diagnoses. We simply haven't taken the necessary courses to make a determination beyond "basic" problems that are easily testable. (Hypertension, blood sugar levels, etc.)
Once a diagnosis is made, it's not unreasonable for a pharmacist to make therapy suggestions, especially when there are adverse events. This is particularly true today with the PharmDs that are graduating, and who have more clinical experience in making complex decisions than most people think. You won't find pharmacists making diagnoses very often; you're more apt to find them making alterations to existing therapy. Tweaking for optimal performance, as it were.
Pharmacists are already prescribing today
The discussion at Kevin, MD seemed to completely ignore the fact that pharmacists regularly prescribe medications here in the United States already.
You'll find this phenomenon in mostly in VA hospitals and in the Indian Health Services. That is, federal agencies. There are many reasons for this, but they're not particularly relevant to this discussion. Suffice it to say that many of the pharmacists in these two areas of study are quite good at what they do — an acquaintance of mine teaches pieces of Disease State Management (the capstone pharmacy course for fifth year students before they do their clinical rotations) and pieces of clinical pharmacology — and they are well-respected in their specific fields.
You won't usually find pharmacists making diagnoses, but you do see them monitoring patient progress and adjusting medications based on what they see.
In the case of VA pharmacists, they are under the supervision of an MD in much the same way that a nurse practitioner is.
Who's more qualified?
Some people suck, no matter what the letters after their name say. In every field some are better than others; some are downright awful, and others are unbelievably fantastic, and most are somewhere in the middle. It's certainly true that MDs tend to be better qualified to make diagnoses than pharmacists. I don't know of any pharmacists that would argue that point.
But are MDs more qualified to make drug therapy decisions? Ignoring the traditional healthcare provider roles and the kneejerk reaction to say "yes!", I am not aware of any studies that have looked at this, and if they have, what the outcome has been. It would probably be a mixed bag, but I would guess that the number of positive outcomes between the two providers would probably be pretty even.
That's a bold statement, of course, but I expect to see research in this area in the next five to ten years, so we'll have to wait and see. By and large, I would trust a PharmD to make a better drug therapy decision than an NP or PA, though, because a pharmacist's drug knowledge is much wider than a PA's, NP's, and even an MD's.*
All of this boils down to the question of which body of knowledge is best when it comes to making drug therapy decisions: broad and deep knowledge of physiology and pathophysiology or broad and deep drug knowledge?*
Obviously the answer is both, and this is why we'll see a continuing progression towards healthcare as a discussion among colleagues rather than a "dictatorshipship." (For lack of a better word.)
A fun little related anecdote… just two days ago, there was a nurse practitioner who wrote a script for Suprax. Suprax isn't particularly common any longer, the pharmacist on duty wanted to change it. He talked to the nurse, and all she knew was that she wanted a cephalosporin. The problem was, she didn't know of any other cephalosporins besides Suprax.
…
That's not exactly confidence-inspiring, and it happens more than you probably think.
* A pharmacist’s education overlaps with a physician’s quite a bit, and even moreso vice versa. A physician probably knows more than a pharmacist does about physiology and making diagnoses. But in general, pharmacists know more about drugs than physicians do — for a reason: they went to school for it.
Random talking points
everybody and their brother wants to script meds these days….. and dont you dare tell me they want to do it for the public good, they want to do it for one reason only: $$$$
I'm not intimately familiar with the Canadian healthcare system, so maybe the motivation for pharmacists up there is different. In the United States, however, you might see a slight bump in pharmacists' salaries, but not much more than that. The days of the independent pharmacy are largely over due to economies of scale. Retail pharmacists working for big chains don't have any incentive to prescribe more meds, but they do have incentive to take patients off meds. (Less work.)
Basically, a doctor has about as much motivation to prescribe medications as a pharmacist does. This argument is a straw man.
where the evidence that pharmacists w/ script rights are just as good as medical doctors?
In specialized fields, the evidence is there. I touched on it above. Beyond that, there hasn't been any research done simply because pharmacists don't have script rights.
If Canada has a problem with script providers, train more NPs, PAs, and MDs. Thats 3 different pathways to scripting meds. There is no reason to add yet another pathway.
Canada is a free country. It's not simply a matter of "training more" as though people are cattle to be herded one way or the other.
The United States is the same way.
1. What are "basic medications" (that is the ones, that the pharmacists think they should be able to prescribe)? Antihypertensives? Insulin? Steroids? Last time I checked, there are plenty of medication errors and injuries to patients caused by physicians who prescribe these meds.
That statement relies on the faulty assumption that a physician is always the most qualified person to make a therapeutic decision. There is no data that I am aware of to support your claim — or mine. So it's impossible to defend one side or another in any meaningful way.
3. What is the malpractice coverage for a pharmacist?
A lot less than for an MD. The cost will go up when pharmacists begin "prescribing," I can guarantee you that. I use the term prescribing lightly, because I think we'll see more "tweaking" than outright prescribing.
4. And when Wal-Mart comes rolling through Canada (which probably has already happened), and your "neighborhood pharmacist" is transformed into another generic low-paid FTE (full-time equivalent) behind the counter, how exactly is that better than your regular physician?
Just because a pharmacist works for Wal-Mart, doesn't mean they suck. And so long as there's a shortage of pharmacists, they will never be "transformed" into a "low-paid" anything. In fact, Wal-Mart has some of the best salaries for pharmacists, and treats them very well (from what I've been told). They've brought their business acumen to inventory management and apparently made it quite easy to run a Wal-Mart pharmacy.
But they also have the Wal-Mart stigma to deal with, which is one of the reasons their pharmacists are paid more. This is conjecture on my part, but most pharmacists think "Wal-Mart? Why would I want to work there?" so they've got to sweeten the pot somehow.
Beyond this, one's employer doesn't diminish one's education and (ultimately) that one knew enough to get licensed.
Conclusions
Would I trust every pharmacist to make a good therapy decision? No, I absolutely wouldn't. Before I could reach that comfort level, I'd have to see pharmacists taking more CE credits, and not just CEs where you show up, have a nice dinner or what have you, and then automatically get credit for it, as is the case with most of these CEs today. There needs to be a better way of making sure a pharmacist is up on current therapies and best practices.
That said, I would trust a pharmacist over a PA or an NP when it comes to managing complicated drug therapy. There is no question in my mind about that.
There would also need to be a better way to keep (and share!) medical records with other providers. It would be awesome if everyone could be on the same page, but this hasn't happened and won't happen for a while. As we move towards healthcare as a collaboration and discussion, we'll gradually see this occur as a positive feedback loop wherein one fuels the other. I can't tell you the number of times I've wished that I could see a patient's medical records when answering the question "Why am I on this medication?" Pharmacists can make educated guesses, but if the medication can be used for a million and one different things, and so long as they are kept mostly in the dark, that's all they are: educated guesses.
[tags]Medicine, pharmacy, prescriptions, law, pharmacy law, PharmD[/tags]
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[...] I've talked before about how medicine is changing. We're moving towards pharmacists having prescribing rights and medicine as a collaboration among professionals rather than a dictatorship. Friends of mine have long predicted that retail chains will move towards having in-house health clinics staffed probably by a PA or NP, who will collaborate with the pharmacists on-staff to come up with optimal drug therapies. One-stop shopping, so-to-speak. [...]
Pingback by CVS/pharmacy buys MinuteClinic — an imminent move into retail-based health clinics? :: OnThePharm — July 13, 2006 @ 5:13 pm
the article was very nice.. the pharmacists are the health-care professionals whom should be the prescribers.
prescription should be a group work: the physician with the diagnostic, the pharmacists with the pharmacoterapeutic knowledge (prescribing) and so the nurse, to administrate the medicine. that´s the best way to work, i think.
Comment by Marcus Souza — July 15, 2006 @ 9:45 am
[...] I've opined extensively on pharmacists as prescribers, and I've basically concluded that it's not a bad idea, so long as they're not making the diagnosis. (Because that's not part of one's curriculum in pharmacy school.) With things like the CCGP certification, do you really need doctors who specialize in old people? [...]
Pingback by Replacing doctors with pharmacists in geriatrics? :: OnThePharm — January 8, 2007 @ 2:28 pm
This is not going to become a major trend in america becaue its incredibly cost inefficient.
Why the hell would I pay 2 "providers" for doing the job of 1? We already spend more on healthcare than any nation on earth, and your response is that we should spend even MORE money by putting pharamcists in the loop?
Wrong answer. We need less spending on healthcare not more. Having one person diagnose and script for treatment is much more cost effective than having 2 people doing the same job.
Comment by john l smith — January 9, 2007 @ 6:39 pm
Actually it's more cost effective because you'd see the doctor less often. Once a dianosis is made, it's relatively trivial for someone else to manage it.
Comment by RJS — January 9, 2007 @ 6:57 pm
I was randomly surfing the internet and came across your blog. Your answers into the changing face of health care caught my eye. As a little back round I am a LPN and in nursing school in Washington. I'm starting pharmacy school next year. I was a nurse in the Army and as such have seen and done more then my title allows. You make some interesting points and I absolutely agree with you, the system is changing to be a collaboration of specialties. For an example, nurses are not being taught to simply follow the doctor's orders, but to be a true patient advocate and suggest various changes to a treatment regime based on the individual patient. There is not a single reason that a pharmacist should not work with the medication regime of patient's a long term care facility, that is their specialty. The physician's role would be best left to diagnosis of a disease, but in order to diagnose a drug regime can sometimes have to be altered. For this reason I think that the role of the PA and NP should be altered and limited to diagnosis, the pharmacist role would be that of medication regime for the diagnosis, and the physician's role would be to accept or alter the two if they see fit. This would take pressure off of the physician's and allow other's their specialty. This would probably save money as the physician could concentrate on more acute illnesses and more minor or chronic situations could be seen by less expensive specialist. As for some of the comments that you tackled in your blog, someone needs to remind the physicians out there that not every infection is a highly contagious and rare disease, also that health care is about the person, not the title!
Comment by Nicholas Mozena — April 28, 2007 @ 11:09 pm
bravo. I agree completely with you…. I am struck with terror with a NP or a PA comes into my examing room, My level of education is higher than theirs, i usually just force them to give me the medication i want! I believe that in most cases pharamcists actually teach the pharmacology part of Nursing and PA schooling, in essence i want to waork beside a gp that hands me a diagnosis and says here, give me the best therapy. after 6 years and 9 clinical rotations i think that we should be trusted by the healthcare community enough to know our stuff!
Comment by kp — June 19, 2007 @ 11:39 am