In order to make sure everyone understands what collaborative agreements are, linked below are a description of what should be defined or included in a collaborative agreement for pharmacists working at the VA and an example of an actual collaborative agreement from the NCBOP web site.
After reviewing the documents linked above, I would like you to consider the following:
Is it appropriate for physicians to write a position paper defining the role of other healthcare providers?
Do you find the paper complimentary, insulting, neutral?
What aspects of the paper led you to your opinion(s) in the question(s) above?
20 comments:
I agree with the article that pharmacists do not have the exposure and experience to diagnose patients. However, I believe that pharmacists do have the knowledge to determine which medication works best for certain disease states and that the prescribing of medications should not remain solely under physician authority. The whole point of patient care is to do what is best for the patient and the easiest way for this to happen is through the collaboration of physicians and pharmacists and even other healthcare professionals when necessary.
How does the hierarchy among healthcare providers affect the relationships between them? (Such as the interaction between a MD/PharmD)
In your experience, do you think a physician has more knowledge about what drugs are appropriate for treatment of a patient?
Even though we feel collaboration between healthcare professionals is necessary in providing optimal patient care, do you feel that a hierarchy within the healthcare system is necessary as well?
Do you think physicians have the right to consider pharmacists to be a lower level health care provider?
Where do you see the expanded roles of pharmacists going in the near future?
Do you believe a pharmacist being part of a collaborative healthcare team would potentially save the facility money that could otherwise be spent on settling drug prescribing errors lawsuits?
In your practice how have you experienced/seen physicans and pharmacist collaborating together? How do you feel about having the ability to prescribe?
The article was fair in the sense that we are not trained to diagnose. I don't know many pharmacists who want to diagnose. I was disappointed the article did not mention that a growing portion of pharmacists are pursuing residency training. I agree that we are limited in what we can do as all pharmacists are PharmD's. That is where certifications, residency training, and fellowships come into play. With that additional training I feel pharmacists can and should have an active role in which medications are prescribed. But we as pharmacists must understand that physicians prescribe based on experience and not from a year-long therapeutics class. It is up to the pharmacy education system to make sure students get enough exposure to hands-on learning vs. book learning. Simply memorizing guidelines does not make you capable of prescribing drug therapy and I think that is what makes physicians nervous. We must promote our training so they understand what we are capable of. Fancy letters after your name are useless if people don't know what they mean :)
I did my residency at the Asheville VA were pharmacists have prescriptive authority in anticoagulation, diabetes, HTN, and lipids. Currently I work in similar disease state programs but operate under a scope of practice which has restrictions on what I can and can't do. In my opinion, not having full prescriptive authority has not significantly impeded my ability to help patients, which is the primary goal right? We must not lose sight of our common goal as healthcare professionals. Again, as we all discussed before, it comes down to relationships. If the physician knows and trusts you good things can happen...
1. Almost everything on earth distills down to: "How do I get/maintain control?" This situation is no different. I think the person(s) who have the most responsibility AND LIABILITY should have control. We all know who that is.
2.The paper was written in 2002. I am continually amused by 'papers' because they always say - ..."significant more study is needed......." to reach a conclusion. My question is - since this was written in 2002, has there been a conclusion? This is six years later.
3.My conclusion - I have seen this phenomenon throughout my working life - some individuals have great concern over pecking order and "..am I a professional" more so than the tasks that have to be accomplished. Stay within your strengths and the pecking order will fall into line by itself.
During my community pharmacy residency I worked with a physician that was also a pharmacist. He greatly valued my input throughout my residency and even wanted me to continue practicing with him as a result of the outcomes he had seen in his patients. He continues to keep a pharmacist on staff for medication management and education. This physician had trained with pharmacists throughout his residency and he saw the differences that were made when pharmacists were integrated into the healthcare team.
After my residency, I obtained a position as a clinical pharmacist practitioner in two different physicians' offices. The dynamic was different with each physician. One physician only allowed medication review and disease education, without any changes in therapy. He just requested that we record recommendations in the patient's chart for his review upon their next visit to him. The other physician was very confident in pharmacists medication management and allowed me to write prescriptions and provide samples with his signature. He was very open to my input and we both saw major changes in the patients in his office. I agree with the article that the physician should be the one to diagnose, but through collaboration with pharmacists there can be better medication therapy management and even more education of patient to control their disease state. It is important that pharmacists continue to demonstrate their importance in the management of patient care, otherwise physicians will not be able to understand our role and may continue to have the same opinions presented in this paper. I agree with dldixon, that the collaboration between physicians and pharmacists comes down to the relationships and trust that have been formed.
I have never thought about it this way before I started pharmacy school, but pharmacists have to sell themselves as the new partner and specialist/practioner within the healthcare team. The old days were glorious when the pharmacist was the uncontested expert on chemicals and compunding. After drug manufacturing and prepackaging started the role of the pharmacist as the chemist started dwindling and shrinking until he became a mere dispenser of drugs. We see a great number of patients who come to the pharmacy and drop off their prescription and want it to be ready within 5 minutes and they will tell you " all you need is slap the label on the bottle".. well gee! that won't take me but 30 seconds. Moral of the story, the fact that physicians are resisting the fact that pharmacists could be an integral part of the healthcare team is because pharmacists trapped themselves in that image of the drug dispenser. So what are we to do? I believe that we are to sell and show the value of the pharmacist in therapy management and materialize the ideals of pharmaceutical care. I believe that we are on the right track, all we need to do is work on changing attitudes by proving that we are valuable to our partners in the healthcare system. Be it through a residency program or fellowships of any other venue the field is wide open for imagination.
Have any of the eMentors noticed a change in the prevailing attitudes of physicians since this paper was published? Can you share any positive or negative examples that you have encountered personally?
Michael Parker
P-1
First, I would like to say that I do not disagree with the fact that physicians receive a more "rigorous" training than pharmacists. However, if PA's can diagnose and write prescriptions after only 2 years of specialized training, why can't a pharmacist who has had 4 years of intense pharmacology? Additionally, most of the physicians I've worked with during rotations and have had contact with over the phone welcome our input because they realize our training is more focused on drug therapy! My own physician conceded that he only had 6 weeks of pharmacotherapy. The main focus should be optimal patient care and that can only happen when ALL healthcare providers collaborate.
After thoroughly reading the articles and the comments posted, I believe that a pharmacist is a specialist. Physicians are trained to diagnose but there is no way possible for them to stay current with all the research and literature being conducted on drugs. As a future pharmacist, I believe that a pharmacist should make a dedicated effort to read available literature and understand what one has read. Consequently, there should be a collaboration between pharmacists and physcian to acheive the most optimal quality of patient care.
When you truly meet an MD who is all about patient care, they realize their short comings. One is medications. The information an MD gets is usually from a regurgitated, mutated, version from a drug rep. WE ARE THE DRUG SPECIALISTS!! When a child is sick they call an MD specializing in pediatrics. When a child is has cancer a pediatric oncologist. We are no different. Once we realize that even though MD's are in charge we have a vital role just as a nurse, physical therapist, resp therapist, and any other team member. I go back to my classic ship example. The MD is the captain, a nurse the first mate, we may be the am munitions expert, and so on and so on. The point is the whole goal of the crew is to stay safe and achieve the mission. We are the same. Our mission is patient care. So when health care professionals realize that we are all for the same thing and drop egos. Our true talent of drug specialization shines!!!
I agree that the physician has a more rigorous training in diagnosis than the pharmacists. It would be great to have a physician diagnose and a pharmacist prescribe all in the same office. However, I do not see this happening in the near future, but I think that we as pharmacists should have that as our goal. Instead of fighting with the physicians we need to make them see that we are just different and have our own specialization. We must recognize our differences and combine our strengths in order to provide optimal patient care. I agree with the ship example. We must all work together in order to make the ship sail. The captain can't do it by himself.
The article is right physicians are the top of the healthcare system. However as I have seen it things are starting to swing our way just a little with newly graduating physicians. I am starting to see more communication and duel partnerships with physicians and pharmacist. What I mean is the physican makes a diagnosis, then consults the pharmacist, he determines a regimen and then we monitor it and make sugestions for changes. In some facilities that I have visited pharmacist have been given authority to actually order test and change therapy as they go. This is a huge step for us as pharmacist. The more education and specialization we get the larger our scope will become.
As the article says we dont have the years of practice or exposure to diagnose a patient. This is true. However when it comes to the drugs some PA, NP, and Physicians have told me they only had small fraction of there studies on Drugs. We as pharmacist have the exposure and experience in the department to make appropriate drug decision after a diagnosis has been made.
After all do you want your parents and family member drug choice to be based on the last pharmaceutical rep that last visited the physician.
As a current pharamcy practice resident I am serving as a member of a healthcare team covering the inpatient heme/onc service. As the attendings, interns (first year medical residents), residents (second year), and fellows have rotated through over the past four weeks I have seen the best and worst of an efficient team. I have had a team that openly welcomed and sought out my input, not only for dosing and drug availability questions, but also for therapeutic decisions, recognizing the scope of their own knowledge was limited when it came to choosing an optimal treatment once the source of the problem had been discovered. That being said, I've also encountered a team who saw no use for me, ignored my presence, mocked my suggestions, and insisted that I was "only a pharmacist" and thus could not have anything to offer a team of physicians. Obviously the latter team was more frustrating than the first but you have to be persistent and willing to fight for what's best for your patients. While our training may not be as rigorous, it is much more focused and specialized in the area of pharmacotherapy; even early on in our careers we may not have the clinical experience to support every decision but I do feel we have enough training to offer valid suggestions that should be respected as such... just remember to do what's best for the patient and occasionally and politely remind the team to do the same :)
Morgan
This is Zack…
I do not think it is appropriate for physicians to write a position paper defining the role of other healthcare providers. I believe our profession is partly to blame for letting our roles be dictated by others. We need to take these discussions from blogs and classrooms and act on our ideas. Pharmacists should be the ones writing about what pharmacists can do. Several pharmacy organizations, including very progressive boards of pharmacy (such as NCAP) have made much progress over the years in expanding pharmacist roles. Why are we often ineffective? Is it that we do not have a united voice in one pharmacy organization? Do we really want a broadened scope of practice and additional liability? Are we willing to work for it?
Getting physician buy-in can be challenging at times. While some embrace and understand the utility of a pharmacist others are strongly opposed. These changes will not happen overnight. It is important to take advantage of small opportunities. One of the school of pharmacy residents here at VCU has been setting up collaborative practice agreements as part of his program. He has been given almost complete autonomy at an indigent blood pressure clinic but has been met with much adversity down the road at an endocrinology clinic where they will only allow him to teach diabetes education classes. He is using this opportunity to get his foot in the door and show what he is capable of doing and this group has allowed him to expand his role.
Parts of this paper are complimentary, including discussion on compensation, use of pharmacists for patient and provider education, as immunizers and involvement in therapeutic substitution. Apart from compensation these areas are now well established. Opposition to independent prescriptive privileges and initiation of drug therapy is not surprising. You do have to consider who is taking the most risk and as of right now this is the physician. It would have been nice to see more about residency training and other areas that pharmacists can have an impact such as smoking cessation.
I think the hierarchy in healthcare will always be there. This is apparent even among physicians (surgeons, generalists, and other specialists…). I do not feel it is right for physicians to treat you as less important or qualified but I also don’t feel it is important to get caught up in who is on top of the food chain. I agree with Mr. Webb in that we need to stick to our strengths. Pharmacists have a vast knowledge about medications. You learn to pose your interventions as questions or change orders in a way that is less abrasive. You must learn to pick your battles and there will be inflated egos in both the physician and pharmacy world. It is just as important for pharmacist to be careful about hiding behind the phone when discussing issues with physicians or nursing. I have seen many pharmacists in both the hospital and community loose their temper when confronting a nurse of physician.
I see pharmacists collaborating with physicians and midlevel practitioners everyday. I am fortunate to be training in a place where pharmacists are common in most clinics and inpatients services throughout the health system. I would say our job is easier in a way since other practitioners are used to interactions with pharmacists. I also feel that pharmacists do have more knowledge about which drugs are most appropriate. With the number of medications patients are on today it is hard for patients and the multiple physicians they see to keep up. We also play a major role in triage (especially in community pharmacy) and it is important for us to be trained to identify issues beyond the scope of OTC therapy and when to refer patients to their PCP or the ED.
In my opinion the most important things we can do to advance our scope of practice is to be more vocal in showing what we can do (residency training can help you learn what you are capable of), choose our battles wisely (we must be assertive but not abrasive), be satisfied with small steps and stick to what we are trained to do.
Post a Comment