Comments on: Pharmacists as prescribers of medication

By: Prof. Dr. Ricardo de Souza Pereira

Prof. Dr. Ricardo de Souza Pereira — Sun, 07 Jun 2009 01:34:00 +0000

I am Scientist and University Professor in Brazil. I am Pharm.D., Master of science in Biochemistry, Ph.D. in Organic Chemistry and I did my post-doctoral at Yale University Medical School. I read the comments and I think that physicians don't know anything about internal medicine. I remember that eleven years ago in New Haven, I was very sick. I saw a physician in Hospital of Yale University and he told me that I had asthma. WRONG DIAGNOSIS!! I had a tremendous infection in my bronchial tree. I took ciprofloxacin twice a day for 7 days and my "asthma" gone.
Three weeks ago, in Tres Coracoes (city where soccer player Pele' was born), Brazil, a white girl, 13 years old, had a tremendous pain and she did not urinate for 15 days. Diagnosis made by 3 physicians:
Physician 1: The patient had a stone in her kidneys;
Physician 2: no diagnosis. Physician prescribed BUSCOPAN which contains scopolamine – a drug used to nocturnal enuresis. Scopolamine is used for children who urinate at night. This drug causes urine retention. Remember: the patient did not urinate for 15 days!!
Physician 3: no diagnosis. He prescribed the same of physician 2.
MY DIAGNOSIS AS PHARMACIST: cystitis. That's what caused the retention of the urine in this patient and the pain. I treated her with antibiotics and the problem gone.
In short: I treated about 1,600 patients in Europe, USA and Brazil. Most of them (98%) with wrong diagnosis made by physicians in USA, Europe and Brazil.
Recently, I invented a formula with melatonin, vitamins and aminoacids for healing giant ulcers (UNTIL 3.2 INCHES) which is typical of HIV positive patients, gastritis and gastroesophageal reflux disease (GERD). I treated 351 patients with the formula in Holland, Italy, USA and Brazil. The results were published in Journal of Pineal Research in October/2006.
I am the sole author of the paper. Please see the link:
http://pt.wkhealth.com/pt/re/jpin/abstract.00005208-200610000-00001.htm;jsessionid=KrWfjBysW4rcpFRcBTms7Tsb2msPsB6Cv4Xqb26QlH9mXWjwK90J!-1260103914!181195628!8091!-1

THIS IS ANOTHER MEDICATION THAT I INVENTED FOR HERPES (USING MELATONIN, OMEGA 6, MAGNESIUM):
http://pt.wkhealth.com/pt/re/jpin/abstract.00005208-200805000-00005.htm;jsessionid=KrXM4mnRbvRtSDJL4npX1GX1Gk6BdBpQbTy2h6pTgRCPqXYnzCSh!-1260103914!181195628!8091!-1

After this, I gave several interviews for magazines and newspapers in USA, Europe and Asia.

See one of them in France:
http://search.yahoo.com/search?p=ricardo+de+souza+pereira+and+la+nutrition&fr=yfp-t-501&toggle=1&cop=mss&ei=UTF-8

In United States:
http://www.vitasearch.com/CP/experts/RDSPereiraAT10-30-06.htm

I am changed everything wrong made by physicians. I am proud of it. Because I AM VERY COMPETENT PROFESSIONAL.
Prof. Dr. Ricardo de Souza Pereira

By: malik

malik — Fri, 13 Mar 2009 00:42:09 +0000

all the arguments aside, will the pharmacist be able to do lab work like CBC, PT/INR, HbA1c, Chem14, lipid panel… because the last time i checked, i ask all my patients to keep a BP log and Blood Glucose log so that i can manage their medication. If they are on warfarin then i monitor their PT/INR to manage their dosage. I would check their HbA1c every 3 months to see if i need to change their insulin dosage. I would check their lipid panel and do chem 14 with liver enzymes to see if their simvastatin is working and is it causing any liver or kidney problems.

now if i want the pt. to come see me in one month to go over his or her labs because i think that i may need to stop/change the medication i initially started them on then i dont see a reason why a pharmacist should continue to refill the medicine and take the risk of killing a patient. For example, i start a patient on warfarin 3mg and i want to check his PT/INH on regular basis and i want the pt. to come see me so we can discuss any change in dosage. The patient decides that he or she does not want to see the doctor because he or she feels fine and just wants a refill their warfarin and get on with their life. The pharmacist refills the prescription but the lab results showed abnormal INR. The pharmacist did not know this and the patient died because had a stroke. REASON? The strength of warfarin was not high enough to prevent clot formation.

Now if we are trying give “script rights” to pharmacist because we want to help patient avoid another doctor visit then you are helping patient die sooner by making it difficult for the physician to monitor the progress of the medicine and any lab abnormalities caused by the medicine. If the reason is that you cannot get a hold of the doctor to get approval or denial on refill then in that case, the pharmacists already have the authority to “LOAN” a 3 to 6 day supply to the patient and mention that in the “REFILL REQUEST” faxed to the doctor. If the reason is that the pharmacist knows more about a drug and its side effects and therapeutic index etc. then I’m sure all pharmacists know more about all the side effects, AUC etc. but how one determine that the side effects are because of the medicine without looking at the lab work. If I was suspicious of a drug causing side effects then I would stop the medicine until I get the lab work back ( eg, if pt. was bleeding from his nose and is on warfarin then I would stop warfarin until I get INR/PT results back ). In this situation, I don’t see a any reason for anyone to be given the authority to write a prescription for any other medication in the mean time. If anything, we should be talking about taking away prescribing writes in these situations.
Now comes the issue of, “the pharmacist can always call the lab or the doctor’s office to get the lab results and made a decision based on labs just as well or even better than an MD”. Really! If you can call the doctor’s office to get labs results then why can’t the pharmacist simply request for a refill? How is a phone call for lab results any different from a refill request.
In case of a phone call for lab results, you will ask someone to either read you the lab results or fax you the lab results so you can look at them and make a decision. If the labs are normal then it’s all good and dandy, you can give them a refill and the pt. will come to the pharmacy next month for their next refill without going in for another lab. You will tell the patient one of two things, 1. “Here you go Mr. john Doe, I have given you another refill on your warfarin but you have to go do your lab work soon” or 2. “I’m sorry Mr. John Doe, I cannot refill your medicine until you go get your labs done”. Now I don’t see a point in this. You will basically be making the patient run in circles and creating more confusion rather than simplifying the matters putting patient at a higher risk of having a medical problem ( eg: stroke).
In case of a phone call for a refill request, the physician will look at the lab results and see if it is ok for the pharmacist to refill the medicine or does the patient needs to come in for more labs because previous labs were inconclusive or maybe they need to come in for a change of therapy. Now this makes more sense because the physician will give at least 3 refills if he wants to check the patient’s labs in 3 months. for someone else to extend those refills without consulting with the primary physician would mean that you have ignored the lab work and skipped straight to the treatment without looking at any other aspects. In such a case, the pharmacist will no longer be able to say that they know more about side effect more than an MD. It’s one thing to memorize all the side effects and a completely different to be able to go look for the side effects even when you don’t see them.
To end this very long post of mine, I would like to add that I have worked in a pharmacy for 3 years as a pharmacy technician and I respect the pharmacist for their knowledge of all the drugs and their different dosage and the knowledge of their side effects. The pharmacists working in a retail pharmacy have always a hard time with filling the prescriptions on time, counseling patients as they pick up their medications and just verifying the work done by pharm techs. I think that pharmacists are hardly able to handle what they already have and are overpaid for the little amount of work they do. Some pharmacists are just power hungry. I have worked with over 20 pharmacists both at Walgreens and walmart, both before I was in medical school and during my time in medical school. I do not think that any of the pharmacists during the time period were anywhere close to being qualified to prescribe or even recommend an alternate therapy. Most of them only knew what the doctor wrote on the prescription, “you need to take this twice a day” and if you have any problems, call your doctor immediately.
CONCLUSION: pharmacist are not qualified to make changes in therapy

By: Sara

Sara — Mon, 17 Nov 2008 03:44:27 +0000

i found this very helpful..i am a 4th year nursing student from the university of manitoba in canada. one of my assignmnets was to do a debate on this topic..yes i agree that our system is moving to a more collaborative approch. The comment about the nurse practioner ordering the antibiotic is proof that phar's should be making decisions about medication therapy…why are they not being used to their full potential?

By: JS

JS — Thu, 21 Aug 2008 22:34:13 +0000

I'm extreme impressed by the sheer professionalism in which this post was written. I completely agree with your stance on this topic. Too often, professionals indulge in unnecessary power struggles. It seems that the basis for the tension among these very prestigious and well respected professionals is due to a fear of loss of authority over a small part of the healthcare process. I foresee a future in which there will be strong collaboration between PAs, MDs, NPs, PharmDs, etc. I believe this change is coming sooner than we think.

By: kp

kp — Tue, 19 Jun 2007 15:39:33 +0000

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!

By: Nicholas Mozena

Nicholas Mozena — Sun, 29 Apr 2007 03:09:15 +0000

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!

By: RJS

RJS — Tue, 09 Jan 2007 22:57:28 +0000

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.

By: john l smith

john l smith — Tue, 09 Jan 2007 22:39:24 +0000

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.

By: Replacing doctors with pharmacists in geriatrics? :: OnThePharm

Replacing doctors with pharmacists in geriatrics? :: OnThePharm — Mon, 08 Jan 2007 18:28:06 +0000

[...] 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? [...]

By: Marcus Souza

Marcus Souza — Sat, 15 Jul 2006 13:45:34 +0000

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.

By: CVS/pharmacy buys MinuteClinic — an imminent move into retail-based health clinics? :: OnThePharm

Thu, 13 Jul 2006 21:13:45 +0000

[...] 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. [...]