A hierarchy exists among healthcare providers. Our physician colleagues are clearly positioned on the top rung of the ladder. This position as the leader of the healthcare team or healthcare system led 2 groups of physicians to write a position paper defining the scope of pharmacy practice and the role of the pharmacist in the delivery of healthcare to patients.
One of the primary methods of expanding the scope of practice for pharmacists is through collaborative practice agreements. 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?
12 comments:
Do you think the pharmacist writing a prescription is in the patient's best interest?
Lauren Hawkins
l.m.hawkins@wingate.edu
Do you feel that position papers by physicians limit or respectfully define our practice as pharmacists?
Sunny Rockhill
s.m.rockhill@wingate.edu
What do you think the role of the pharmacist should be in the future? What role should we play in the care of the patient(i.e. diagnosing and writing prescriptions)?
Bryant Summers
b.b.summers@wingate.edu
Prescriptive rights is a fascinating concept for us pharmacy students, how do you feel as a practicing pharmacist about limited prescriptive rights? And what types of conditions should we have rights to? Do you think this is the direction pharmacy is going towards?
I can understand why a doctor wouldn't want a pharmacist who practices in the community to have prescriptive rights, but why wouldn't a doctor want a clinical pharmacist who works with patients in a hospital setting to have prescriptive rights?
Sarah Murphy
P1 Student
Please give us specific examples of situations in which a pharmacist's authorization to prescribe would have resulted in better patient care.
Virginia
v.e.bailey@wingate.edu
What is your opinion on pharmacists having prescriptive rights?
-Stephen Rivas
This debate here is more egos and turf vs ability. In practice, community and institutional, I have seen so many physicians prescribing without a reasonable understanding of how to actually order the medication. I will cite a surgeon who berated me for not informing her what the difference between "N" and "R" insulin was before she prescribed to cover a patient's accucheck with Humulin N. I receive many calls daily about antibiotic use.
I have seen very good collaborative relationships between physcians and pharmacists in the institutional setting. We are consulted to help dose Warfarin, Vancomycin, gentamicin and many renally affected medications.
It really should be a welcomed thing, where the pharmacist is knowledgable and experienced. From my viewpoint with Wingate students, you will be very prepared to perform these duties.
I feel that it is nice to be recognized as an important part of the healthcare team. I also think pharmacists need to do a better job of informing other practitioners of our expertise. We should be the ones writing about what we can do and pharmacists are commonly publishing research and other scholarly activities. We should define our practice but need to remember that having physicians on board is important to our success in expanding clinical roles. Often hospitals and clinics will not be knocking down your door to hire a pharmacist. It is important to seek out those types of positions, to network, and know what types of services you are capable of offering. This is where knowing where to start and writing a good collaborative practice agreement come into play. Residency training helps with experience in writing collaborative practice agreements and gaining experience in settings where agreements like this are in place.
To answer some of the posted questions:
Yes, I feel that pharmacists that are able to write prescriptions do this in the best interest of the patient. As I work in primary care settings this year, patients are referred to me and I am able to follow them more frequently than they are able to obtain physician visits. This can be very important in many patient populations, DM, HTN, dyslipidemia, renal disease, anticoagulation, and asthma/COPD. Unfortunately there is a shortage of providers and often physicians, CRNPs and PAs can only spend 15 minutes with patients per visit. We also offer services such as tobacco cessation counseling, leading DM classes, and help with medication access such as patient assistance programs. And this is only a handful of areas. Certainly we should be able to initiate and change therapy in these settings.
There is data in primary care as well as acute care that pharmacists improve patient outcomes by saving money, improve safety, reduce error, and increase medication compliance. Pharmacist in acute settings are involved in entering and verifying orders and help select/adjust the most appropriate therapy for patients in addition to many other interventions described in Joe’s post.
In my experience, if you approach collaboration with physicians in the right way they are very open to your expertise. Fortunately I have trained in some very “pharmacy friendly” facilities and in these settings physicians notice when the pharmacist isn’t there. In some cases there isn’t funding to put a pharmacist in each area they are requested.
Lastly, I would like to add a thought about liability/responsibly. Remember wider the scope of practice you seek the more responsibility you take on. I am able to order labs at the Baltimore VA. If my patients glucose comes back at 44 or I get an INR of 10 I am now responsible in deciding what to do.
Zack Deyo
University of Maryland
zdeyo@rx.umaryland.edu
Here is an example of a multi-disciplinary collaborative medical team in a teaching hospital. I am the pharmacist part of the department of anesthesia inpatient pain management service and we see patients daily to manage their pain. These are patient who have just had surgery and are recovering, patients with chronic pain who have had surgery, or chronic pain patients having difficulty with pain control. The team consists of an attending anesthesiologist, resident anesthesiologist, pharmacist and advanced practice nurse, NP or CNS both with prescription writing privileges. We review the patient’s chart, medical history, reasons for pain, medications and progress, interview and examine the patient and develop a new plan for the day. I as the pharmacist am the drug expert. The team does look to the pharmacist for suggestions, advice and contributions to the patient’s care plan. The physician makes the diagnosis and most of the time looks to me to suggest the medications and dosages to treat the problem. Chronic pain patients are a difficult population to treat as they have multiple co-factors affecting the pain, like tolerance, anxiety, depression and others. We use many different medications delivered not just in a tablet or capsule, but topically, IV, infused around specific nerves, epidurally and intrathecally (right onto the spinal cord). You have to know a lot about every drug choice. Since this is a teaching hospital I have many chances to educate both the patient and resident physician every day. Drugs, doses, how do they change from an epidural infusion to tablets and drug-dose equivalent calculations, are what I get to do every day. I do not have prescriptive authoritive, but I know another hospital (in Montana) that has developed pharmacist collaborative prescribing agreements with physicians. These pharmacists manage all of the pain problems for the orthopedic surgery department. The start IV patient controlled analgesia (PCA) and transition the patients as they progress to oral pain medications in preparation for discharge from the hospital. We are starting pharmacist dosing of vancomycin and heparin at my hospital right now.
Pharmacists as prescribers is definitely possible and it will challenge you every day. As a prescriber you are now the person responsible for the patient and their outcomes. Your decisions affect real people and your level of responsibility has now taken a huge leap upwards in the patient care area. Your dose recommendation for an antibiotic will help cure an infection, but you will be monitoring for toxic effects and also to see if the patient is really getting better. Talk about job satisfaction when you are right. You will feel like crap, though, when you are wrong . Your pharmacy education, practice and experience will prepare you for these challenges.
Clark Lyda, PharmD, Clinical Pharmacist, University of Colorado Hospital
RE: Lauren/Bryant/Ashley/Sarah/Steven
Personally, I don’t think that pharmacists, regardless of practice setting, need prescriptive rights. Sure, CPPs already can and do write prescriptions based on collaborative practice agreements, but pharmacists in other settings serve a specific purpose. That purpose is to be a double check – offering an expert opinion on the therapy being proposed in an effort to make the best decisions on the part of the patient. Currently, pharmacists are not trained in the nuances of prescriptive authority – how to write prescriptions, how to know when to write prescriptions, and how to document and monitor the patients’ condition after a prescription is written. We are trained in recognizing the best medication – in the best dose at the best time – for the patient. We let the doctors be the patient care managers and we serve as the drug experts. Prescriptive authority could blur our judgment and introduce personal bias into the patient’s care – for example, let’s say a general medicine doctor has just written a prescription for Cipro for a 12 year old girl. By the sheer fact that the prescription has now arrived at the pharmacy, the prescriber was confident in their drug choice, as they handed the prescription to the patient and sent them on their way. When the prescription arrives at the pharmacy, I, as the pharmacist, call the prescriber to double check the use of this medication, as it’s not common to use this class of medications in pediatric patients. When I speak to the nurse, she confers with the doctor, and comes back and tells me that “He meant Keflex... change it to Keflex.” The system of checks and balances ensures that this sort of catch is made; now imagine if that prescriber could have filled the prescription himself and sent the patient on their way (i.e. the situation that would arise if the pharmacist could prescribe). The patient would have received the wrong drug at the wrong time and would ultimately have suffered because their infection would not be resolved. So... long story short... instead of pushing for prescriptive authority, pharmacists ought to move in the direction of enhanced medication therapy management and medication education – this would increase compliance, improve outcomes, save money, and build trust.
RE: Sunny
Position papers are just that - positions. They are opinion-based. There will always be limitations on the scope of a pharmacist's practice, but we need to participate on a higher level to ensure that our scope is not unfairly limited. Organizations such as APhA, NCAP, and the Board of Pharmacy work diligently to showcase the talents of pharmacists. We need to support appropriate legislation and work together to broaden our scope of practice.
RE: Virginia
Every time I get a prior authorization rejection from an insurance company, I could benefit from the ability to perform a therapeutic substitution. I get these PA rejects on medications such as PPIs, steroid nasal sprays, and antihistamines. Having the ability to "prescribe" an alternative would be of great benefit, both to the patient and to all healthcare providers involved. The patient gets a comparable medication at a lower price and in a timely manner while the healthcare providers (doctors and pharmacists) save the time of filing PA paperwork and ultimately get to attend to more patients. I have recently updated my PA fax form to include a box where the prescriber can write for a different drug (that I recommend) instead of doing the PA - so far, every PA that I've sent off has come back with my recommended change.
___________________________
Erica Harms, Pharm.D., R.Ph.
Staff Pharmacist - Target Pharmacy
Charlotte, NC
eharms@carolina.rr.com
Lauren:
I think this question has an answer (as most of these do) somewhere in a gray area. If the physician hands you the diagnosis and you are able to take a complete patient history, then I think us having prescriptive authority is in the pt's best interest.
Tying into Anonymous's question:
I do not think pharmacists should play a role in diagnostics other than a supportive one unless pharmacy schools introduce more of these types of courses into the curriculum. I have certainly helped physicians with a differential, but the key is "helped". Our physical assessment and other courses provide us a GREAT background, but not one at this time I believe to be adequate for diagnostics of all disease states. HTN, DM, dyslipidemia, etc are all diseases I believe we can diagnose and treat most likely better than the physicians.
The problem is we need access to the medical team treating the patient, as well as a complete history to progress to this level, as many pharmacists already have.
Anonymous:
Positions by physicians are just that, positions. I think this article was tasteful, but I think we have a few more years of pushback before we can take pharmacy to the clinical level most of us desire. Physicians like control, and that is why it is SO IMPORTANT that you build constructive, respectful, and trusting relationships with them. Do not be afraid to question them or offer an opinion because the worst thing that can happen is you learn something :).
My vision for pharmacy is for our profession to be viewed clinically with the same respect as the physicians. This is a big step, but when they realize we are the drug experts and they are the diagnostics experts, then we can REALLY collaborate and take excellent care of our patients. This is already happening, we just have to keep showing them how knowledgeable we are and how well we can deal with patients!
As a side note, working in the ER, you really get a feel for what the above is like. Most of the physcians I worked with loved the fact that my interviews and research into the medications could help solve some of their worst cases. I found the problem more than once just because the patients trusted me and because I thought outside the box, and the physicians were very grateful. They saw the potential and used it from then on.
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