A hierarchy exists among healthcare providers. Our physician colleagues are clearly (and rightfully) positioned on the top rung of the ladder. This position as the leader of the healthcare team or healthcare system has led a number of groups of physicians to write position papers defining the scope of pharmacy practice and the role of the pharmacist in the delivery of healthcare to patients.
One such article was written by the American College of Physicians and American Society of Internal Medicine.
Another position statement written by the AMA earlier this year has not been publicly released but a number of news articles and responses have been made available. ACCP had a few recommendations as well.
And finally here is a recent Wall Street Journal editorial about what pharmacists should be doing.
As mentioned in the articles above, one of the primary methods of expanding the scope of practice of 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 papers and articles complimentary, insulting, neutral?
What aspects of the paper led you to your opinion(s) in the question(s) above?
51 comments:
After reading the Wall Street Journal article written by the Dean of USC Pharmacy School I had mixed feelings. I felt that the article did a great job proving that pharmacists can definitely make a significant difference to patients in terms of both health care and saving money. The words "saving money" are bound to catch most patient's attention. However, I felt as if the article was saying that a Pharmacists primary job is to help physicians with their work load. While I do agree that collaboration within health care providers is imperative in providing quality patient care, I believe that both professions should be considered equal.
An aspect of the article that I felt was important was the fact that it mentioned the Asheville project. Not only did the article describe the benefits of pharmacies and pharmacists in health care, but also backed it up with solid evidence and data. Overall though, I was pleased that a credible article was published in a popular media context that illuminated the assets of the pharmacy profession.
It seems like some physicians are still trying to grasp the fact that pharmacists are just as knowldgeable as they are. After reading the VA protocol, I noticed that the agreement made was mostly reffered to physicians. But the NCBOP protocol gives pharmacists alot of authority over the patients.
The medical world in acknowldging pharmacists little by little.
In my opinion, it is arrogant for physicians to write a position paper defining the role of other healthcare providers. The article written by the American College of Physicians and American Society of Internal medicine has a neutral tone until it comes to the part mentioning that only physicians shall diagnose patients. First, it seems to be doubtful about pharmacists’ ability when stating “decisions about the most appropriate drug for a patient’s condition are often subtle and require a level of experience and training that is not provided in obtaining a PharmD degree.”Second, it implies that physicians are better in choosing the medication when adding “in fact… physician training entails many years of practical supervised experience.” Third, it does not appreciate pharmacists’ role when saying the benefit of the physician-pharmacist collaborative relationship is “incremental and not a substitute for that of the physician, whose role is primary.” All of these statements are insulting.
Tai Tran, WUSOP, P1
Because the healthcare system today contains a vast array of associated professions it is suitable that there is a tiered system in place to ensure organization and direction. As medical doctors and other physicians have long been respected for their role and leadership within the healthcare community, it is understandable to me that their opinion will carry a heavy weight in the future establishment of the pharmacy profession. With that said, the more value the pharmacist can exhibit in assisting the physician to achieve favorable patient health outcomes, the better chance pharmacists have to broaden their scope of practice. Therefore, I believe it is favorable that physicians write position papers dictating the role of the pharmacy profession, providing it ultimately leads to increased pharmacist autonomy and an accurate picture of how successful pharmacist involvement can be in directing patient care.
I found the ACP position paper on pharmacists to be mostly an objective and fair assessment on how pharmacists can assist the medical profession. While the paper seemed to assess the pharmacist’s involvement in collaborative agreements in a positive light, there are still some obvious hesitancies that doctors have in granting pharmacist autonomy, especially concerning prescriptive rights. From reading the paper it appears that physicians do not fully appreciate the education pharmacists have concerning prescription drugs; and while physicians recognize that pharmacists are “experts”, they are still somehow subordinate to the physician’s knowledge of the material. I was disappointed to read this. Also, the paper really only agreed that pharmacist involvement in collaborative practice resulted in lower costs to the patient—which is at best a minimal acknowledgement that pharmacists can help patient outcomes. The Ashville Project, for example, did a lot more than just saving people money, it resulting in better overall patient health.
Mentors: Have you had any experiences where a physician did not seem to respect your level of education or expertise regarding knowledge of medication therapy?
--James Burrows (P1 Student)
The article from Maine is a good example that pharmacists are not only healthcare professionals, but also professionals that know what they are doing. It is okay to bestow upon them expanding roles and duties such as vaccinations because they do have the title of a doctor and they do have the educational background. Physicians are always going to be at the top of healthcare and I do understand that their comments could possibly shape the future of a pharmacists. This is why it is important to step up to the challenge and show what pharmacists can do for the public as well as what we can do for physicians. Pharmacists are experts in medication therapy and that is something that physicians can't replace. Of course it is our job as pharmacists to expand our role and set our place in healthcare to help convince those from the Wall Street Journal and any other article that we a serious profession that is greatly needed by the public and other healthcare providers.
- Nick Conley (p1)
I completely agree with Ishita, regarding the Wall Street Journal article. This article seems to saddle the pharmacist with a portion of physicians' workload. Instead of the pharmacist working for the physician, I believe that the two healthcare providers should be in collaboration to accomplish their goals. Position 3, taken in the article written by the American College of Physicians and American Society of Internal Medicine, highlights the fine line between a physician and a pharmacist. It states, "...the goals of the two educational paths are different, as are the outcomes in terms of skill set." Neither profession is better than the other. Likewise, two healthcare providers, one a pharmacist and the other a physician, should not regard themselves as equal. Each profession is very important to society's quality of life. And for each profession to spark even greater change among society, we must collaborate as a team, realizing what part each profession can contribute to the team.
Regarding scope of practice, I believe that physicians alone should not define the scope of pharmacy practice. I do not believe that physicians would like for pharmacists to determine their scope of practice. I feel that each profession's scope of practice should be defined by a board of healthcare professionals in which each healthcare profession is represented.
P1 - Amanda Flores
I do not feel as though physicians should be able to define the role of other healthcare professionals. I agree that they are, and rightfully so, at the top of the hierarchy of healthcare, but they have not completed the same training as pharmacists, nurses, etc.
I have a question for the mentors: Have you ever been in a situation where the physician prescribed an incorrect medication, and when notified about the mistake, refused to do anything about it?
Even fifty years ago, this topic would never be considered a discussion, yet as we all know, things change. In recent history, the number of medications on the market has increased at least ten-fold; the total cost of healthcare has risen exponentially; and the total health of the population has declined beyond belief. Doctors have always been at the top of the healthcare hierarchy, but again, things change. As insulting as the AMA position paper was to our profession, this line of thinking has been the status quo for far too long. Those in power want to stay in power. The AMA feels justified by the “old guard” in writing this paper to keep other healthcare providers “in their place”. I unequivocally disagree with this line of logic. Evidence can be found in the modern version of the Hippocratic Oath penned by Dr. Louis Lasagna from the School of Medicine at Tufts University in 1964, “I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery” (Wikipedia.org). Since this is the widely used modern version of the Hippocratic Oath graduating physicians take, I would like to see them accept pharmacists and other healthcare professionals as such aforementioned colleagues with the skills necessary for a patient’s recovery. The data is mounting as evidence for the benefits that pharmacists can provide all across the board, yet it is still not enough. With the world of healthcare changing in the near future, pharmacists can alleviate the stresses of immunizations and chronic disease management. Ultimately, physicians feel threatened that business will be taken from them while using the disguise of “lack of education” as their only argument. The pharmaceutical educational field has undergone multiple adaptations recently to appease this opposing view. The PharmD degree requirement has become the industry standard while many pharmacy school prerequisite requirements now include a third year of pre-pharmacy studies or a bachelor’s degree, as well as the potential for mandatory residency programs. If either or both of this educational requirements become a standard, what (if any) leg does the medical community have to stand on in denying the autonomy of pharmacists?
-Cole Herrell, P-1 WUSOP Student
We actually discussed collaborative practice agreements today in another class and I thought it was comforting to know that a lot other healthcare professionals are acknowledging the full capabilities of today's pharmacist. However, after reading the articles listed, I no longer felt a sense of comfort. I felt a sense of defensiveness. As much as working together with other professionals benefits us, I think that it means a little something different to us than it does to them. For example, immunizing pharmacists today get certified to immunize people because it saves the public money and it creates a more convenient means of getting your yearly shots. However, I think physicians see the as something we're doing only to make their jobs more productive. And I think that's something that could not go unnoticed in the articles. A physician may "hold the top rung" of the healthcare ladder, but that doesn't mean they have any right to delegate the responsibilities and/or capabilities of a pharmacist.
As stated in the blog, physicians are the top of the ladder when it comes to healthcare. They put in more time in school, training, and in every other aspect of the preparation for their future. I feel that gives them every right to voice at least their opinion on the scope of practice of the other healthcare professions. The first article uses good reasoning in determining their opinions. They are not trying to condemn pharmacists; they are simply using their experiences as a healthcare professional to form an opinion on the subject. I may not agree with every aspect of their ideas, but I will definitely respect them.
I have to admit the position of physicians. They are considered as the healthcare profession leader. Therefore, I think it is alright if they write articles about scope of pharmacy. They have the rights to evaluate and criticize about pharmacy area. However, pharmacists are improving dramatically nowadays so that they also have their own publication and it's considered as professional articles. So I think as pharmacists, we have a deep sight and understand more about what is going on than physicians.
Moreover, physicians study deeply into specific diseases so they have ability to diagnose rather than pharmacy. But about medication treatment, they have to value pharmacists' role, who are expert of drugs. In the articles, it seems to be neutral tone; yet, still a little bit not really consider about pharmacists' value.
The bottom line is pharmacists are trying their best to make a new change for our pharmacy profession; we can definitely prove to the society how important we are in healthcare system.
Ngan Tran -P1
Going off of what James B. said, I agree that the tiered system of health care professionals helps to ensure organization and structure in the health care world. In reference to the position paper written by the ACP, I think that their position at the top of the tier does give them validation in making statements concerning the scope of practice of other health care professionals (after all, it's an opinion, not enacted legislature). I think that the tone of the paper was accepting of the expanding role of the pharmacist while at the same time being mindful of their own territory as primary health care providers. I think many of us can acknowledge that physicians do typically undergo a more rigorous training process than pharmacy students, although we are still able to play an important role in the grand scheme of things through professional collaboration.
The Wall Street Journal article was obviously a bit more biased on the pharmacist side of things, but I did enjoy the use of hard facts and evidence that support our continued and expanding involvement in patient care. Like we discussed in "Prof. Resp. & Leadership" this morning, it is sometimes difficult to get the message across if it doesn't come from a "noteworthy" source. I think that seeing such an article in the Wall Street Journal will help raise public awareness of the importance of pharmaceutical care.
I personally believe that one of the biggest obstacles pharmacists have is explaining to people that we do way more than just count by fives and stand behind a counter. When I was accepted to pharmacy school, my friends were happy for me, but truly do not understand what it is I will actually be doing besides dispensing drugs. I think it's so important to be advocates for the profession, and collaborate rather than compete with other health care professionals including physicians, nurses, and PAs. Each healthcare professional is educated in different aspects of providing health care, and we shouldn't argue about who holds the most or even "better" knowledge to treat a patient, but rather work together to help treat the individual to the best of our ability. While I am sure there are many physicians that are stuck in their ways of pretending that pharmacy as a profession is not advancing, I believe that most recognize that not only pharmacy, but also healthcare in general, is changing, and a change will have to be made sooner or later.
Caitlin Mullins
P1 Student
Looking back on history, the physician is the primary care provider for patients; and to a certain extent they still are today. But as a collaborative effort between pharmacist and physicians, pharmacists are becoming more knowledgeable and are able to perform more tasks. With this said, I do believe that physicians should have some say in the role of a pharmacist, but in some ways I believe that the physician may be scared that a pharmacist can do their job, and possibly do it better. Going through school we are being taught pharmaceutical care, and to have a patient centered mindset. Therefore, I believe that pharmacist and physicians should work together to help the patients, rather than complain or start a conflict between the professions. For example, the vaccine’s that pharmacist are able to give now; physicians freely gave this up because they were losing money and time; so, they saw that a pharmacist can do this and it gives them an opportunity for advancement while helping take some workload off the physician. Its things like this that keeps these professions together. With a collaborative effort physicians and pharmacist can continue to prosper in both practices. An example of hostility is from the American College of Physicians and American Society of Internal medicine article, when it mentions the prescriptive rights on medication. Yes, I do believe that as an upcoming pharmacist and for the practice itself, we do have the knowledge to prescribe medication to a patient. But as the devil’s advocate, isn’t this stepping into their territory? If we have prescriptive rights, what else is there for a physician to do? When we encroach on their field of practice this starts to become personal. Would you like for a physician to take over and begin to dispense our medications? If they did so, what would be left of the pharmacy profession?
Josh Waters P1
PIn the AMA news article seeking to limit the Pharmacists’ scope of practice, Dr. Manasse made a very compelling argument in favor of a pharmacists’ knowledge. Dr. Manasse noted the extensive science, pharmacology and therapeutics education a pharmacist receives in school compared to that of a physician. He mentions that most physicians do not actually learn appropriate prescribing until their residencies. This acknowledgment of the pharmacists’ educational triumphs is well deserved. I do not feel it is appropriate for physicians to write a position paper defining the role of other healthcare providers. I would not suggest a pharmacist write a position paper criticizing the roles of a physician, unless I had been a physician myself. The same should apply for physicians without a true understanding of the education we receive.
~~Chrissi Tyrrell, P1
In my personal opinion I agree with the statements made in the Scope Practice by the American College of Physicians and American Society of Internal Medicine. I agree that physicians are highly educated and trained to diagnose disease states and medical conditions and that the pharmacist is trained and skilled for the pharmaceutical aspect of treating such diagnosis. I was very pleased to read the information supplied in this article and I am honored as a pharmacy student that the ACP-ASIM published this article speaking positively about the skills and abilities the pharmacist does have and is able to provide and expand on. In regard to this paper I do think it to be appropriate for physicians to define the role of healthcare providers. On the contrast of this scenario I do not agree with the statements of the AMA in regard to defining the role of nurse practitioners or other health care providers. I am highly convinced that the AMA lacks valid reasoning due to the papers released by the ASHP and the ACCP correcting and clarifying the statements submitted by the AMA. In addition a particular article truly hit home with me and it was the collaborative agreement from the NCBOP defining the scope of treatment areas for the pharmacist as cleared with the physician. I am from the High Point, NC area so I am familiar with these facilities and I have heard these names. I was inspired to see the level of change and the applicable effects of the movement of pharmacy on such a local level. It really drove the realistic application of everything for me!
To the mentors: Are you inspired at all by the local changes you have witnessed or experienced regarding the Scope of pharmacy practice as it is today and as it is becoming for the future? In other words do you see yourself opening new doors for the profession of pharmacy outside of or abreast to the scope of pharmacy?
Tiffany Benfield
P1
Like Tai, I found the position paper written by the physicians defining the role of pharmacy slightly insulting but I feel as if they are justified in writing this. In healthcare, a tiered system is the norm and physicians are on the top of it (and rightly so). I believe the insulting nature of the position paper is an incentive to improve physicians' opinions of us as pharmacists. I believe that is an opinion that will only change through personal experience. A physician is not going to just wake up one day and decide that a pharmacist's role should be extended.
The Wall Street Journal article focused on the fact that pharmacists should be able to help alleviate the load of physicians. I think this is true and while this is slightly degrading to think that our job would only be to help physicians, this is how we will improve our reputation in the physicians' eyes. Since in order for our profession to evolve we need the physicians' support maybe it wouldn't be such a bad thing to suck up our pride and "help physicians". I think that is the most effective way to earn respect without stepping on too many toes.
-Hollee Kitts P1
I'm not going to say I blame physicians, I mean, I would be upset too if a more trusted heathcare professional wanted to do more with the patient, wanted to save not only the patient but the heathcare system money, and wanted to improve our "customers'" quality of life. Especially since we, the professional drug dealers, are so under qualified and so under educated to do the job. Anyone feel a sense of sarcasm?? Okay, I understand that physicians are on the top rung of the healthcare ladder, but does that really give them the right to tell us how to do our job? The answer is no. Does this give physicians the right to 'allow' us to do certain aspects of our job? Again, I would have to say no. Example, say that Mrs. Yadayada comes in to your community pharmacy to pick up her Lipitor. "Lipitor" sounds a little off to you so you check her medication history and see that her doctor has recently changed her from the generic fenofibrate to the brand name cholesterol medication. Being a responsible, knowledgeable pharmacist you ask when was the last time that she had a LFT ran? "A LFT?" she replies. So you explain to Mrs. Yadayada what a Liver Function Test is and how she needs to have one completed every 4 to 6 weeks for about the first year and a half of therapy. And, let's just say that her physician (and I know this would NEVER happen) was overloaded with patients and just accidentally forgot. In this example, we as community pharmacists couldn't order a LTF. Why, in this example, would we need to have a physician's signature or approval just to order a simple test? What the physician wants, is for us to call his or her office, speak with a nurse, and set up an appointment for Mrs. Yadayada so we can bill her insurance for not only the test but also for the office visit; all so a nurse can come in and tell poor Mrs. Yadayada that her liver is fine. And to me, this is what it's all about: MONEY. Physicians are afraid that if pharmacists start giving vaccines and taking a look at someone's chart they will end up losing money in the long run. And as long as physicians are on top of the hierarchical ladder, this will never change! That is, unless we change it for them.
Eric Beamon
WUSOP P1
I think that the American College of Physicians and American Society of Internal Medicine had great intentions with publishing the article regarding the scope of practice for pharmacists. I find it very unfortunate that there were apparently so many inaccuracies though. I think ultimately their goal was to open the minds of physicians and other health care providers to the idea that pharmacists can play a much larger role than they did in the past. Although clearly the ASHP and the ACCP were sensitive to the fact that there were many false or inaccurate statements (which is totally understandable), I think the American College of Physicians and American Society of Internal Medicine accomplished what they set out to do with the article. However, they definitely should have considered at least consulting with some pharmacists before publishing the article.
For the most part, I find the papers to be complimentary.
I’m glad that at least someone is sharing some kind of notion that the role of the pharmacist in today’s society is extremely valuable. Whether the argument is made in terms of finances, patient outcomes, or the reduction of drug-related adverse events, pharmacists can make a huge difference in health care. I think it is a great thing that they are being recognized by other health care providers and gaining more attention, credibility, and recognition.
Ultimately, it is stirring up conversation and I think it will help to propel the profession in a positive direction.
Amanda Hill, P1 Student
I also after reading the articles had mixed feelings, especially after the Wall Street Journal. I agree that it is a great opportunity for us to help monitor patient's diabetes and similar diseases, but not only to lighten the physicians for other jobs. By offering the patients counseling on their diabetes, we are not replacing the role of a physician, we would simply be fulfilling the role that their physician does not have time for. I think it's great that we are being more recognized as to what we can and should do, but society needs to realize that we are not doing these services simply to aid physicians in their work load, instead we are offering these services to the patients because of the valuable insights and information we are able to provide them with.
These are great articles that present opinions from different sides. I do feel like the largest barriers are money compensation, time, and "turf wars". The physicians clearly state our roles, or what they think our roles should be in the healthcare world. It is true that physicians go through training that is more intensive regarding diagnosis and treatment, but pharmacist training isn't far behind. I think the papers focus a little too much on the comparisons between the two professions, and the reasons why pharmacist shouldn't be able to do certain things. Most of the arguments have solutions that most pharmacy schools are addressing. I do think that the physician's responsibilities that were listed should be separate and clearly defined from those of the pharmacist. The most important thing is for pharmacist and physicians to collaborate so that patient outcomes are positively maximized.
Current pharmacist and mentors, how do you feel your current collaborations are working?
Do you feel like you have the knowledge and confidence to fulfill of the responsibilities listed in the papers above as pharmacy moves forward?
-Blake Milam P1
I found that the articles were mostly positive. It was finally shedding light on the importance of the role of a pharmacist. All of the articles made it a point to show that collaboration is very important to give well rounded care to our patients. What I found disappointing was that after stating how imperative a physician and pharmacist relationship is, the article by the ACP still stated that this collaborative effort should be “solely up to the physician” to decide. How could you publish a paper stating that something that is proven to improve the care of a patient should be optional and also that you should be compensated for this? The responsibility of any health care professional is to do anything necessary to care for a patient and improve their state of being. Why should we be paid extra to do something that is our responsibility? I agree with Erin’s response, in that the physicians are at some level, trying to mandate the entire health care field, when it is a team effort. We all play equally important roles in caring for our community; the physicians may be the “head” in a sense, but pharmacists, nurses, PA’s and all other health care professionals are the legs, arms and bodies that work as an entire unit. One part without the other cannot exist as a whole.
Ashley Reese- P1
In response to Eric and Tai,
While I can understand both of your perspectives, we should also consider that the ACP-ASIM article is endorsing what is essentially an expansion of the scope of pharmacy as it is understood outside our profession. This is leverage we can use to move ourselves toward the footing we want. We can't come in demanding roles that we have not yet proven ourselves capable of performing, and we must solidify the new roles we have assumed before biting off more than we can chew. Remember, if we look at health care as a team sport the physicians are still the team captain.
James Barbery
Referring to the position paper wrote by physicians, I believe that physicians are afraid of change. They are used to being at the top of the ladder with no other profession remotely close to present a challenge to their expertise. Now that Pharmacy has developed through the years, especially with increased education and training, physicians feel the professional gap between the two narrowing. I believe statements such as the one posted is one way that physicians are trying to combat this change and downplay pharmacists, along with many other growing professions such as nursing, physical therapy, etc.
John Miller P1
I, personally, did not find the Pharmacist Scope of Practice paper by the American College of Physicians and the American Society of Internal Medicine insulting at all. I actually was happily surprised that they acknowledged all of the abilities in pharmacists and emphasized that physician-pharmacist collaboration is ideal for patients. Some may have found a bit harsh the fact that they so explicitly stated that only physicians should be allowed to diagnose and prescribe medications to patients. In reality, only physicians are properly trained for these functions. As pharmacists, we should not expect physicians to just let us prescribe and diagnose when that has not been our education’s focus. Having said that, if the proper education were available for pharmacists and they were willing to attain it and become qualified for these duties why shouldn’t they be able to perform them?
The AMA statement, on the other hand, could be considered insulting to the pharmacy profession. It clearly did not consider the many benefits pharmaceutical care offers patients and was simply comprised of false information, which, in my opinion, should completely discredit their whole statement. And like some nursing associations stated, “It is not appropriate for one health professional group to attempt to discredit the quality of education, credentialing and practice of members of another profession.” Their statement reflected little professionalism and respect towards pharmacists.
Alisha Rivera-Menendez
WUSOP P1
I am not one for politics. I think the focus needs to be shifted away from comparing Doctors to Pharmacists and start outlining what each profession is capable of doing. Doctors go to school to diagnosis diseases and learn about treatments. They have very little schooling in how drugs work. That’s where pharmacists come into play. We have a basic idea about how diseases are diagnosed, but we receive extensive training on how drugs work at a molecular level. I think as a profession, we need to stop saying we are as good as doctors or we could do their job better. We are comparing two different things. Our knowledge base is different; therefore our jobs will be different. You could also look at our roles for patient care as attacking the same problem from two different angles. I think doctors diagnose a disease and outline the best way to treat it. Pharmacist could take the doctors’ prescription orders and manipulate the drug to maximize the outcome for individual patients. As health care providers, do we not have the same goals? Treat the disease accurately, effectively, and the most cost efficiently way possible. Then why do we “play” for different teams? We should be one large “team” of members with different insights. I see the collaborative efforts guiding the healthcare profession in the right direction.
P1 Tyrsa Creel
Like many others seem to have, I have mixed feelings regarding the articles. I am glad that articles are getting published about the growing responsibilties of pharmacists by sources outside of the world of pharmacy. The vast majority of people still think that all pharmacists do is count pills, just reading and hearing about how the profession is changing will allow people to accept these changes when they see them in practice. I'm glad more physicians are accepting collaborations with pharmacists but there were some things written that would clearly upset any current or prospective pharmacist such as physicians stating our roles followed immediately with "while physicians provide safe, effective care to patients", as if patient care is not at all in our job description.
I agree with Dr. Nuzum in that physicians rightfully occupy the top rung of the health-care ladder. They have the longest history, and the highest level of education. The public knows this and looks to them as authority on health-care. However, with the increasing number of new drug and drug classes becoming available, physicians would be overwhelmed without pharmacists. It has been my experience that some physicians have very little knowledge of the drugs they prescribe. Pharmacists have become an essential component of the health-care team. I look forward to seeing us develop a greater symbiotic relationship with physicians.
Andrew Herrin P1
I agree with Ishita in the fact that I felt like the article was mainly expressing the need for pharmacists to help physicians with their work load and to help cut health care costs. It is important to remember that even though saving money is great, it is important to keep the overall health and benefits of the patient in mind. I feel some physicians are a bit too over reactive when it comes to the roles that pharmacists have today. All health care professionals need to keep in mind that roles change as society changes. We have discussed that machines are now able to count pills for pharmacists, but we are finding more ways to work in the field of medicine. We are trying to view this as a benefit rather than a loss of job functionality. We have made wonderful advances to further deliver exceptional care to patients and it will continue to improve. I am sure that physicians will find other ways to provide as well, considering ALL fields of medical care are changing.
Question for the mentors: If pharmacists are the most trusted profession by the general public, why do you think physicians have such a hard time trusting us when it comes to expanding SOP? Is it ego, toe-crushing, or a valid and meaningful line-drawing?
Mariah Whatley (P1)
I like to think of pharmacists as consultants – highly trained professionals offering an expert opinion on the topic of pharmacotherapy and medication management. We are trained in recognizing the best medication – in the best dose at the best time – for the patient. We let doctors be the patient care managers and we serve as the drug experts. As evidence to that effect…
My best story about “incorrect medication” comes in the form of a script for Levaquin 750 mg qd for a 12 year old girl for sinusitis from an urgent care doctor. Seemed like a bit of overkill to me, seeing as Mom had told me that the girl had not failed prior antibiotic therapy for this infection… coupled with the fact that I’m a bit more cautious with fluoroquinolones (especially high-dose FQs) in kids, I gave the prescriber a call. I expressed my concern over (1) the use of the FQ with the data regarding arthropathies in kids (see eFacts), (2) the high dose, and (3) the fact that the girl was an avid gymnast, thus possibly exacerbating the risk of arthropathy, and (4) the fact that she hadn’t failed prior therapy. The doctor said to me, “You and I both know that that tendon rupture thing is an overblown side effect that no one ever experiences. Fill it like I wrote it.” I proceeded to counsel the mother on the medication and expressed my concern in using the drug for her daughter’s sinusitis. The mother agreed with my recommendations and went back to the urgent care to get the doctor to write for a different drug. The best part of the story is that the very next day, the FDA put a black box warning on all FQs for risk of tendon rupture... confirming the cautious use of FQs in certain patient populations.
I challenge you all, especially during your IPPE time, to think about how you would handle situations like these. If a doctor stands firm on how they wrote a prescription, even though you know it’s “wrong,” do you refuse to fill the medication? Do you counsel and document? Do you do nothing because the doctor said it’s ok? You’ll need an effective communication strategy for conveying concern and a “best interest of the patient” attitude while not “attacking” the prescriber for dosing/prescribing incorrectly… and an effective way of expressing your concern to the patient without scaring them. While they may not like to admit it, doctors can and will make mistakes, just as pharmacists can and do. Successful communication between providers ultimately prompts the best outcomes for the patient, which is the fundamental goal of the healthcare team in the first place.
_________________________________
Erica Harms, Pharm.D., R.Ph.
Executive Pharmacist | Target Pharmacy, Charlotte
eharms@carolina.rr.com
I had written my post before reading Dr. Harms's personal account. As I read about the egotistical physician it only further cemented my views on healthcare.
I have always found it ridiculous that some doctors (not all) come in with a superiority complex about healthcare. Granted they are one of the leading healthcare providers, but as the number of patients increase a negative correlation is found with the healthcare provided. Wait times in doctor’s offices, emergency rooms, and in-patient hospitals are not getting any smaller and doctors are getting less time to spend with their patients. People will spend an hour in a waiting room even if they have made and appointment and when they get in the doctor talks to them for a total of five minutes and sends them on their way. Is that patient care? NO! If these doctors started embracing having other healthcare professionals taking on roles that they are proven to be well educated and effective in then doctors would have the time to focus on other aspects in healthcare that pharmacists, nurses, PA’s etc are not as knowledgeable in. It will allow patients, who need certain critical care that only a doctor can provide, more than a five minute time allotment, and it will allow the doctor to fully assess the situation rather than having to go on instincts, which everyone knows are not always correct. I think it is against the statement that doctors will do their patients no harm if they don’t consider other factors that may be more effective and beneficial to their patients (for example pharmaceutical care). If pharmacists are able to provide the care that a patient needs just as well if not better than the physician then I believe they should have that right. Pharmacists are jumping through all of the hoops that are being laid out for us, we go through years of school, we get doctorates, we get hands on patient experience, we go on to specialize in specific field, and we get the necessary certifications needed to provide the quality of care that is expected by a doctor performing the same task, and yet certain groups of people are still trying to hold us back. Patient care will not be at its peak until healthcare providers learn to fully work together rather than fighting a branch’s efforts to improve upon their profession.
I think we should not compare anything between pharmacists and physicians. They both are doing great jobs which serve our society and we all appreciate that. Who are better who have higher position is not really important because they have to work together in a team - "collaborative agreement" - is a matter. In order to help patient prevent disease, cure disease, etc, physicians need pharmacists and vice versa. So why don't we try to help each other in healthcare professional field? It will be benefit for not only patients but also pharmacists. We can develop our field with the support from physicians and patients, don't we?
So I mean because patients need pharmacists, especially community pharmacists who are available anytime for them, we are building up patients trust and also physicians. The future of pharmacy is up to next generation -us- so keep it up!!!
Ngan Tran - P1
I can't say that I blame physicians for wanting to define the position of pharmacists, especially considering the fact that nurses have taken it upon themselves to provide many primary care services. I do believe, however, that physicians should not have the right to completely dictate the pharmacy profession's future.
As the healthcare world evolves, I expect to see these kinds of discussions continuing. I do not believe that any pharmacist wants to take the role of physicians. Rather, they want to be able to provide excellent service to patients and cut down on drug morbidity and mortality.
Eventually, we will come to a mutual understanding of every healhcare professional's specific role in providing care. Pharmacists are in a great position right now to be a major player in the healthcare system of the future and I don't believe that another profession is going to have to define or limit our scope of practice.
The physicians should have an opinion in the matter because they are at the top of the healthcare field, but it should not define the role of another healthcare field. Since pharmacists now are all required to get their PharmD degree, education and knowledge has increased. Therefore, pharmacists know what they are able to do and we need to show the public a little at a time what we can do until the roles have changed in the direction intended.
Shawn Jessup
P1
WUSOP
Physicians are certainly (and rightfully) at the top of the ladder that is the healthcare system. That in itself gives them some right to discuss and determine (NOT dictate) the scope of practice for other healthcare professionals. Collaboration and communication are both absolutely necessary, as we are all human and therefore all capable of making mistakes. By working in collaboration with physicians, we can cut costs, improve patient care, and increase the efficiency of the healthcare system. I have to say, it's most important to focus on making the most of all healthcare professionals as a team in order to best serve the patients, and that includes physicians, pharmacists, PA's, nurses, anesthetists, etc.
I do not find these articles to be offensive. I'm glad others are taking notice of the valuable and changing role of the pharmacist.
-Brittany Samples, P1
I think the collaboration of pharmacists and physicians is needed to optimize patient care and nurture us into a new era of healthcare. The role of pharmacists as well as many other health professionals is changing and some of that change involves work with physicians. To make this transition as easy and effective as possible the support of physicians is needed. I think it is perfectly acceptable for physicians to write papers defining the roles of other healthcare providers as long as they are similar to our own. Although from a physician’s perspective a pharmacist may just be someone to “complement” the physician (The Wall Street Journal Article) but as long as the way in which we define our new roles is the same it should allow for better patient care and pharmacists taking on a more active role. Pharmacists are not and should not be trying to start a power struggle with physicians and allowing and accepting their help is an essential part of defining a successful new role for pharmacists.
“Have you had any experiences where a physician did not seem to respect your level of education or expertise regarding knowledge of medication therapy?”- James Burrows
“Have you ever been in a situation where the physician prescribed an incorrect medication, and when notified about the mistake, refused to do anything about it?”- Chris Skowronski
James and Chris, yes and yes. The degree of resistance will vary depending on whether you work retail, community hospital, teaching hospital, etc, but you will ALWAYS be questioned on your knowledge/recommendations by physicians (and anyone).
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“To the mentors: Are you inspired at all by the local changes you have witnessed or experienced regarding the Scope of pharmacy practice as it is today and as it is becoming for the future? In other words do you see yourself opening new doors..?”- Tiffany Benfield
Tiffany, we have a LONG way to go. Although I am very happy at what we are doing, the scope of pharmacy practice isn’t as well known as we are made to think and that really hinders our profession. A key part of my day is that I frequently make trips up to the MICU during the afternoon. Rounds usually last from 830am-11 or 12. I usually return again around 2 or 3 and chat and discuss patients for 30 minutes with the docs. I then usually ask if the nurses need anything from me. I hope by just being present, it helps increase awareness and reinforces the fact that I can be relied on. When you are seen as a reliable resource, it does wonders for yourself and your profession, and I believe opens doors for others.
Simple example of how little our scope of practice is known, I recently went to a clinic and spoke to a ARNP. We got to talking about what I did and I mentioned that I was a clinical pharmacist in a MICU. I thought, her being in the healthcare field, would understand, but she had no idea. I had to describe my job in detail and she was amazed. Furthermore, even in the field of pharmacy, many pharmacists have no idea what my job entails.
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“Current pharmacist and mentors, how do you feel your current collaborations are working?
Do you feel like you have the knowledge and confidence to fulfill of the responsibilities listed in the papers above as pharmacy moves forward?”- Blake Milam
Blake, I do not have a collaborative practice set up; however, I will answer your second question. I do not believe, even with residency training and 2000 hrs of IPPE/APPE from pharmacy school, that I have the full knowledge I need to practice. However, I do not believe I ever will. A key is that I continually educate myself and that gives me more confidence to practice and make recommendations.
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Matthew Nguyen, PharmD
Maricopa Integrated Health System
Clinical Pharmacy Specialist
MICU, CICU, Adult-Emergency Medicine
“Question for the mentors: If pharmacists are the most trusted profession by the general public, why do you think physicians have such a hard time trusting us when it comes to expanding SOP? Is it ego, toe-crushing, or a valid and meaningful line-drawing?”- Mariah Whatley
Mariah, all of the above. For some it is ego/toe-crushing. For others it is valid. To be honest, there are many times I find myself slapping my forehead because of the questions I get form other pharmacists (whether it be retail or hospital). Although you all are only in your first year, there is a story I was told that I just love and really emphasizes the range of pharmacists’ knowledge.
While in school, we had to do a poster night. My friend’s project was on vancomycin, which you will all learn is an antibiotic that is NOT absorbed orally. Another fact you’ll learn about this medication, is that drug levels need to be drawn when given intravenously to ensure you are in a safe range to not harm the patient, but to make sure you are high enough to treat the infection. So as my friend’s group presented their topic, they received a question from a pharmacist:
“Would you check levels for a patient who is receiving vancomycin orally on an outpatient setting after being discharged from the hospital?”
My friend answered: “No, I would not.”
So the pharmacist states: “Wrong, you should always get levels for vancomycin.”
So the pharmacist goes on about an elaborate story about how she received an order for vancomycin by mouth for 7 days and contacted a physician to make sure the patient was set up for an appointment to get a level drawn.
Now, I am not sure if the physician actually followed up (I hope not), but this just shows why some physicians feel that pharmacists do not deserve to expand their practice. Why on Earth would we need a blood level on a drug that is not absorbed when taken by mouth?
I know this does not describe all pharmacists, but we all know that when something goes wrong, it sticks out more. So again, it is ego and valid.
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Matthew Nguyen, PharmD
Maricopa Integrated Health System
Clinical Pharmacy Specialist
MICU, CICU, Adult-Emergency Medicine
I feel that many people are unaware of the scope of pharmacy. The fact that these articles are being published can only help pharmacy move forward. Yes, we are not going to agree with everything that is published, but at least people are discussing the profession and are taking notice to the responsibilities of a pharmacist. I agree with Sarah that health care professionals should keep in mind that ALL the roles are changing and that we should work together in order to benefit the patient. I felt that the Wall Street Journal article was complimentary to pharmacist and showed how pharmacy was expanding more towards patient care.
Tiffany Humber P1
I currently have Scope of Practice in the Anticoagulation, Lipid, Medication Management and Heart Failure Clinics at my hospital. The oversight? When I first got the physician signature for my Scopes, the doctor said, "don't kill anyone" and handed me the paper. Since then, the only oversight I've had is through monthly reviews of five of my notes done by a rotating coworker. This goes to show that, even though many Scopes are determined and legally supervised by physicians, the actual practice is oftentimes autonomous in nature.
Also, because I work with the VA, I can make medication changes, order new meds, order labs and schedule follow-up without prior approval of a physician.
Living the dream!
Its is claer that the future of healthcare will require increased collaboration between the pharmacists and physicians and other providers. Physicians have a right to express thier opinion about what other providers should be doing but dont have the right to define or set standerds for them. We as pharmacists should set set and define our standards whose ultimate goal should be increased patient care and safety. Physicians should remain the "leader" in patient care but i think the future dictates increased prescribing privelages by pharmacist. Pharmacy carriculums should change with the industry inorder to train and equip pharmacist to perform these roles.
When I first began reading the article written by the American College of Physicians I was pleasantly surprised. For the first page or so I was thinking that they actually respected the profession of pharmacy and the direction that it is taking. However, when I got further into the position statements, I was shocked. Physicians think that because they go to school longer, they are at the top of the food chain. Some of the things described in the article I found to be very insulting. From this article, it was very easy for me to conclude that the only thing that physicians want from pharmacists is for us to take over their busy work, such as immunizations. However, we it comes to a more forefront change such as working directly together, physicians seem to get very territorial and defensive. Apparently no one else will ever be as good as them.
Katelyn Agee - P1
The "Pharmacist Scope of Practice" paper published by the AMA came across to me as a bit over zealous in defining where pharmacist's should draw the line at what they can do. For example, on page 84 the article concluded "...the practice of medicine remains with physicians." However, in my opinion, collaborating with other health care professionals IS practicing medicine. If physicians are are practicing medicine correctly (aka not promoting "quackery"), then other health care professionals going in behind them and reviewing their diagnosis and conclusions and therapy (even to the point of having power to CHANGE, with a physician's permission) shouldn't be a threat, but a comfort. I don't find it surprising that physicians would try and define the pharmacists scope of practice as I agree that it does affect their own practice and their time. However, why can't we as pharmacists make the final say on what direction our profession goes in? Sure, let's collaborate, but as far as what pharmacists DO, let pharmacists DECIDE and PROVE through statistical studies and hard data and research that we we are doing IS best for the patient. Then, once the results are in, the physicians may have to adjust their practice to mold to what is best for the patient, even if that means conforming to a new and changing role of the pharmacist.
After reading the article from the Wall Street Journal, I feel that the Dean undermined the profession of pharmacy, making it seem that our sole purpose was to lighten the load of the physicians. I agree with Ishita in saying that both professions should be looked at equally. Today, pharmacists are equally as important as physicians and are just as well trained in our line of practice. The world of pharmacy and all other health care professions is expanding. We need to embrace this expansion and grow in our scope of practice.
Allison Hoyle
P1-student
Start with the idea that pharmacy could do more than dispensing drugs. Our pharmacy nowadays improve dramatically (i.e. they can do immunization vaccine, etc. ). The meaning for all of these is just because of patients' benefits, for health and for cost. And this improvement is based on patients' trust which mean we are doing a good job so that they need our help. But then, physicians and other professional healthcare thought we want to take their role in health care system. So I think pharmacy published medication can help us prove that we are doing for society good not for us. Therefore, we can keep developing but still have collaboration of other professional healthcare.
After reading the Wall Street Journal article, I would say I feel like some of the other students and have mixed feelings on the issue. While it was a well written article and like Ishita mentioned, it was nice seeing something like this in a popular media, it seems to stress the point that an expanded scope of practice is all about saving money. I guess I would have to say that the position papers aren't quite insulating, but they're not neutral or complimentary either. I think the idea of physicians accepting a pharmacist's scope of practice will just take time.
Beth Campbell
P1
Although I consider pharmacy to be a crucial part in a person's well being, I still believe that physicians hold more knowledge and experience necessary for choosing the type of treatment to pursue. This is not to say that I think pharmacists should not be allowed to prescribe medications, but my opinion, even after reading the ACP position paper, is that a pharmacist should at least be allowed to approve refill requests for maintenance medications. As stated in the Wall Street article, with more people under insurance coverage, there will be a shortage of physicians, even though the ACP paper opposes prescriptive rights for pharmacists, giving pharmacists partial authority would be a better option. Most people that are taking medication are taking some form of maintenance medication and with the help of other medical providers in combination with pharmacists, the load on a physician could lessen. I do believe physicians know more about diagnosing a patient and deciding what steps need to be taken, but the pharmacist could help by choosing the best medication based on the treatment the physician wants the patient to follow. Working together will always lead to better outcomes.
-Maryann Choy-Ames
P1
Since the medical is taking a new direction on medical breakthroughs, some medical responsibilities should be the duties of pharmacists and pharmacist alone such as providing patients pharmaceutical care. If physicians can put their ego aside and collaborate with pharmacists, a lot of suboptimal healthcare issues can be avoided.
I really liked the Wall Street Journal article. It well defined the role of the pharmacist as it was set out in the Asheville Project. I was, however, not surprised with the physicians' outlines. They really want to keep prescriptive rights. I don't really blame them, but I don't agree with the idea that PharmD training doesn't provide sufficient drug knowledge to at least alter drug regimens. I think we as pharmacists are on the right track. We just need to keep hounding legislature.
It has been a while since we have had this discussion but I wanted to share the conversation that I had with a physician over the past weekend. The person who sat next to me in the plane when I was coming back from Virginia happened to be a physician who specializes in internal medicine. He saw me flipping through my top 200 PowerPoint notes and asked me if I am a med student. I told me that I am a first year pharmacy student at Wingate University. I also told him about how the field of pharmacy is evolving and becoming more of patient-centered care and some of the progresses that are taking place through MTM and other pharmaceutical care services to improve the health care system. He looked very confused when I mention to him how pharmacist can have a huge impact in patients’ lives by helping them manage their medications through MTM and other pharmaceutical services. This is what he said to me “pharmacists have a fraction of knowledge comparing to what we have and it’s our job to help patients manage their medications so I don’t see the whole point of MTM.” He said “pharmacists have huge role in identifying any drug interaction and catching prescription errors but other than that everything is on the computer so it’s easy!” Without expressing my frustration by his ignorance about pharmacists’ role in the health system, I did my best to convince him how pharmacists are more knowledgeable about drugs and most accessible health care profession. I explained to him patients that have chronic diseases visit their pharmacist about eight times more than other patients and pharmacists are in a key position to help patients manage their medications and assess any drug related problems.
After having this conversation I have realized that pharmacists and pharmacy students must be highly proactive to make collaborative practice become more realistic in every corner of the health care system. There are many physicians out there who either don’t know or don’t want to know about pharmaceutical services that pharmacists provide. Therefore, those of us who work hard to improve the health care delivery, must work together to demonstrate a huge achievement in the health care system by practicing more of pharmaceutical care. This way, different health care professionals will accept our pharmaceutical services for the well-being of their patients.
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