Pharmacists as prescribers of medication

I was reading on Kevin, MD the other day a post about pharmacists “wanting” to prescribe. The article was about Canada, but we’re rapidly moving in that direction here in the United States as well, with the PharmD degree being the only one that’s offered.

This article is pretty long, so you may wish to get a cup of coffee or something before you read it, but I do think it’s very relevant to healthcare today. The sections:

  • The retail misconception
  • Healthcare as a collaboration
  • A problem of medical records?
  • Making a diagnosis vs determining treatment options
  • Pharmacists are already prescribing today
  • Who’s more qualified?
  • Random talking points
  • Conclusions

There was quite a bit of excited discussion in the thread, and I wanted to address some of those things here. Some were legitimate concerns, and some were just plain wrong. I have mixed feelings about being able to prescribe someone medication. On the one hand, it would be terribly convenient to alter drug therapy when the prescriber can’t be reached, but on the other hand, that’s quite a bit of additional responsibility. (Not from a “getting work done” point of view, but rather being directly responsible for therapeutic outcomes.)

In my experience dealing with most pharmacists and most pharmacy students, most of them chose the path because it paid well, was relatively stress-free,* and while it was challenging to make it through, the financial and personal rewards at the end made it worth it. Not because they’re necessarily passionate about being a pharmacist. Naturally, there are exceptions to these rules — such as yours truly; I truly love medicine in general and pharmacy in particular — and this phenomenon isn’t even a bad thing. There’s nothing wrong with not being passionate about what you do. (Though I do think that actively disliking one’s job is a recipe for disaster, particularly if you are a pharmacist.)

One of the reasons for this lack of passion is that being a pharmacist is largely a passive role in healthcare. The most exciting and interesting parts of my day are the discussions I have with patients about XYZ. Those are the moments that make what I do truly worthwhile. I think a more active role in healthcare would cause a lot of pharmacists to be happier about their jobs. Not that I think that job satisfaction should be a reason to involve pharmacists more actively — rather, I think that involving pharmacists more would results in more positive therapeutic outcomes if for no other reason than they are more accessible than any other provider.

* Where stress-free is defined as work stays at work when you leave, not that working in a retail environment is without stress, because this is most certainly not the case.

The retail misconception

First off, not all pharmacists are retail pharmacists. That is, of course, what everyone thinks of when they think of a pharmacist, but the majority of RPhs out there don’t stand behind a counter all day and count pills. They do other things. When we’re talking about pharmacists prescribing meds, we’re not necessarily talking about your neighborhood pharmacist. That’s probably the biggest misconception out there — even among other healthcare providers.

Discussion-based healthcare

Medicine is slowly but surely moving towards a more collaborative style of managing outcomes. This stems from the fact that breakthroughs occur faster than any one person can keep up with, which in turn results in specialization. Everyone in healthcare knows this intuitively, even if they perhaps haven’t sat down and thought about it in such explicit terms.

In many cases, pharmacists — especially clinical pharmacists specializing in something, e.g. geriatrics — knows more than your average GP when it comes to dosing and drug interactions in general in their field of study. This is often why you’ll find pharmacists supervising physicians in managed care settings like nursing homes. In their field, they’re quite simply better at making the right decision because they know more about that particular aspect of patient care. I can think of two different clinical pharmacists who regularly sit down and work out the pharmacokinetics for drug regimens for specific trouble patients. These two people are incredibly well respected, and when they make a treatment suggestion, it is always followed. (And I’m not aware of a single case where they’ve been wrong.)

This is the collaboration I’m talking about. Mostly it applies to difficult patients: those on lots of meds or who have idiopathic symptoms — which are often the result of drug therapies unsuitable for those with impaired liver and renal function. Being able to tweak these meds without having to call for a doctor’s authorization would be wonderful (and is wonderful in the settings where it occurs).

Ever tried to call a doc’s office and get a response within a reasonable amount of time (20-30 minutes)? Hah! It rarely happens. Naturally this is because docs are incredibly strapped for time, and I sympathize, but it does make getting an approval immensely frustrating. It’s also frustrating for the patient, which is why pharmacists are consistently considered the most accessible healthcare experts in the field. These are all problems the medical profession knows about, and I think it will eventually get better.

And pharmacists are going to keep medical records where? And how are they going to prevent duplications?

There are three problems with this argument.

1) More than 50% of our patients (especially the elderly) see more than one doctor. You think they’re sharing medical records in perfect accord? Well, I can assure you they probably aren’t. I’ve seen quite a few drug interactions because Doc A doesn’t know what Doc B is doing. Trusting a patient to facilitate conversation between the two providers is nothing short of laughable in most cases.

2) The other problem with this argument is that most patients go to the same pharmacy all the time, regardless of who the doc writing the script is, which puts the pharmacist in a unique position. I don’t know what is meant by duplication, but if that person is referring to getting the same drug twice, the insurer simply won’t allow it. Ironically, this means that insurers are helpful in tracking down therapeutic duplications, even if a patient doesn’t go to the same pharmacy all the time. Insurance rejections are, of course, an imperfect solution, but most people have some form of third-party coverage, whether it’s a discount or actual insurance.

3) Because of point #2, pharmacists are better able to see the overall picture from a therapeutic standpoint than Doc A or Doc B alone. If they can’t see it directly, they can respond indirectly to an insurance rejection, for instance, and dig deeper to see what’s going on.

I’ve written extensively on universal access to healthcare records before (not on this site), and this would solve a lot of these problems. However, this is years away. As universal access improves, we’ll be seeing more of this active collaboration, rather than providers all working in their own little vacuums.

Making a diagnosis vs determining treatment options

I wouldn’t trust a pharmacist to know the difference between peritonsillar abscess, viral URI and Lemierre’s syndrome. These would all be treated the same by the pharmacist (no disrespect to them). If someone isn’t trained to do something, why would they want to perform that task?

In most cases, pharmacists don’t want to make diagnoses, so this point is completely irrelevant, and demonstrates a misunderstanding of the difference between the roles of doctor and pharmacist. Every pharmacist I’ve talked to knows they’re not well-equipped to make complicated diagnoses. We simply haven’t taken the necessary courses to make a determination beyond “basic” problems that are easily testable. (Hypertension, blood sugar levels, etc.)

Once a diagnosis is made, it’s not unreasonable for a pharmacist to make therapy suggestions, especially when there are adverse events. This is particularly true today with the PharmDs that are graduating, and who have more clinical experience in making complex decisions than most people think. You won’t find pharmacists making diagnoses very often; you’re more apt to find them making alterations to existing therapy. Tweaking for optimal performance, as it were.

Pharmacists are already prescribing today

The discussion at Kevin, MD seemed to completely ignore the fact that pharmacists regularly prescribe medications here in the United States already.

You’ll find this phenomenon in mostly in VA hospitals and in the Indian Health Services. That is, federal agencies. There are many reasons for this, but they’re not particularly relevant to this discussion. Suffice it to say that many of the pharmacists in these two areas of study are quite good at what they do — an acquaintance of mine teaches pieces of Disease State Management (the capstone pharmacy course for fifth year students before they do their clinical rotations) and pieces of clinical pharmacology — and they are well-respected in their specific fields.

You won’t usually find pharmacists making diagnoses, but you do see them monitoring patient progress and adjusting medications based on what they see.

In the case of VA pharmacists, they are under the supervision of an MD in much the same way that a nurse practitioner is.

Who’s more qualified?

Some people suck, no matter what the letters after their name say. In every field some are better than others; some are downright awful, and others are unbelievably fantastic, and most are somewhere in the middle. It’s certainly true that MDs tend to be better qualified to make diagnoses than pharmacists. I don’t know of any pharmacists that would argue that point.

But are MDs more qualified to make drug therapy decisions? Ignoring the traditional healthcare provider roles and the kneejerk reaction to say “yes!”, I am not aware of any studies that have looked at this, and if they have, what the outcome has been. It would probably be a mixed bag, but I would guess that the number of positive outcomes between the two providers would probably be pretty even.

That’s a bold statement, of course, but I expect to see research in this area in the next five to ten years, so we’ll have to wait and see. By and large, I would trust a PharmD to make a better drug therapy decision than an NP or PA, though, because a pharmacist’s drug knowledge is much wider than a PA’s, NP’s, and even an MD’s.*

All of this boils down to the question of which body of knowledge is best when it comes to making drug therapy decisions: broad and deep knowledge of physiology and pathophysiology or broad and deep drug knowledge?*

Obviously the answer is both, and this is why we’ll see a continuing progression towards healthcare as a discussion among colleagues rather than a “dictatorshipship.” (For lack of a better word.)

A fun little related anecdote… just two days ago, there was a nurse practitioner who wrote a script for Suprax. Suprax isn’t particularly common any longer, the pharmacist on duty wanted to change it. He talked to the nurse, and all she knew was that she wanted a cephalosporin. The problem was, she didn’t know of any other cephalosporins besides Suprax.

That’s not exactly confidence-inspiring, and it happens more than you probably think.

* A pharmacist’s education overlaps with a physician’s quite a bit, and even moreso vice versa. A physician probably knows more than a pharmacist does about physiology and making diagnoses. But in general, pharmacists know more about drugs than physicians do — for a reason: they went to school for it.

Random talking points

everybody and their brother wants to script meds these days….. and dont you dare tell me they want to do it for the public good, they want to do it for one reason only: $$$$

I’m not intimately familiar with the Canadian healthcare system, so maybe the motivation for pharmacists up there is different. In the United States, however, you might see a slight bump in pharmacists’ salaries, but not much more than that. The days of the independent pharmacy are largely over due to economies of scale. Retail pharmacists working for big chains don’t have any incentive to prescribe more meds, but they do have incentive to take patients off meds. (Less work.)

Basically, a doctor has about as much motivation to prescribe medications as a pharmacist does. This argument is a straw man.

 

where the evidence that pharmacists w/ script rights are just as good as medical doctors?

In specialized fields, the evidence is there. I touched on it above. Beyond that, there hasn’t been any research done simply because pharmacists don’t have script rights.

 

If Canada has a problem with script providers, train more NPs, PAs, and MDs. Thats 3 different pathways to scripting meds. There is no reason to add yet another pathway.

Canada is a free country. It’s not simply a matter of “training more” as though people are cattle to be herded one way or the other.

The United States is the same way.

 

1. What are “basic medications” (that is the ones, that the pharmacists think they should be able to prescribe)? Antihypertensives? Insulin? Steroids? Last time I checked, there are plenty of medication errors and injuries to patients caused by physicians who prescribe these meds.

That statement relies on the faulty assumption that a physician is always the most qualified person to make a therapeutic decision. There is no data that I am aware of to support your claim — or mine. So it’s impossible to defend one side or another in any meaningful way.

 

3. What is the malpractice coverage for a pharmacist?

A lot less than for an MD. The cost will go up when pharmacists begin “prescribing,” I can guarantee you that. I use the term prescribing lightly, because I think we’ll see more “tweaking” than outright prescribing.

 

4. And when Wal-Mart comes rolling through Canada (which probably has already happened), and your “neighborhood pharmacist” is transformed into another generic low-paid FTE (full-time equivalent) behind the counter, how exactly is that better than your regular physician?

Just because a pharmacist works for Wal-Mart, doesn’t mean they suck. And so long as there’s a shortage of pharmacists, they will never be “transformed” into a “low-paid” anything. In fact, Wal-Mart has some of the best salaries for pharmacists, and treats them very well (from what I’ve been told). They’ve brought their business acumen to inventory management and apparently made it quite easy to run a Wal-Mart pharmacy.

But they also have the Wal-Mart stigma to deal with, which is one of the reasons their pharmacists are paid more. This is conjecture on my part, but most pharmacists think “Wal-Mart? Why would I want to work there?” so they’ve got to sweeten the pot somehow.

Beyond this, one’s employer doesn’t diminish one’s education and (ultimately) that one knew enough to get licensed.

Conclusions

Would I trust every pharmacist to make a good therapy decision? No, I absolutely wouldn’t. Before I could reach that comfort level, I’d have to see pharmacists taking more CE credits, and not just CEs where you show up, have a nice dinner or what have you, and then automatically get credit for it, as is the case with most of these CEs today. There needs to be a better way of making sure a pharmacist is up on current therapies and best practices.

That said, I would trust a pharmacist over a PA or an NP when it comes to managing complicated drug therapy. There is no question in my mind about that.

There would also need to be a better way to keep (and share!) medical records with other providers. It would be awesome if everyone could be on the same page, but this hasn’t happened and won’t happen for a while. As we move towards healthcare as a collaboration and discussion, we’ll gradually see this occur as a positive feedback loop wherein one fuels the other. I can’t tell you the number of times I’ve wished that I could see a patient’s medical records when answering the question “Why am I on this medication?” Pharmacists can make educated guesses, but if the medication can be used for a million and one different things, and so long as they are kept mostly in the dark, that’s all they are: educated guesses.

[tags]Medicine, pharmacy, prescriptions, law, pharmacy law, PharmD[/tags]

14 thoughts on “Pharmacists as prescribers of medication

  1. the article was very nice.. the pharmacists are the health-care professionals whom should be the prescribers.

    prescription should be a group work: the physician with the diagnostic, the pharmacists with the pharmacoterapeutic knowledge (prescribing) and so the nurse, to administrate the medicine. that´s the best way to work, i think.

  2. This is not going to become a major trend in america becaue its incredibly cost inefficient.

    Why the hell would I pay 2 “providers” for doing the job of 1? We already spend more on healthcare than any nation on earth, and your response is that we should spend even MORE money by putting pharamcists in the loop?

    Wrong answer. We need less spending on healthcare not more. Having one person diagnose and script for treatment is much more cost effective than having 2 people doing the same job.

  3. Actually it’s more cost effective because you’d see the doctor less often. Once a dianosis is made, it’s relatively trivial for someone else to manage it.

  4. I was randomly surfing the internet and came across your blog. Your answers into the changing face of health care caught my eye. As a little back round I am a LPN and in nursing school in Washington. I’m starting pharmacy school next year. I was a nurse in the Army and as such have seen and done more then my title allows. You make some interesting points and I absolutely agree with you, the system is changing to be a collaboration of specialties. For an example, nurses are not being taught to simply follow the doctor’s orders, but to be a true patient advocate and suggest various changes to a treatment regime based on the individual patient. There is not a single reason that a pharmacist should not work with the medication regime of patient’s a long term care facility, that is their specialty. The physician’s role would be best left to diagnosis of a disease, but in order to diagnose a drug regime can sometimes have to be altered. For this reason I think that the role of the PA and NP should be altered and limited to diagnosis, the pharmacist role would be that of medication regime for the diagnosis, and the physician’s role would be to accept or alter the two if they see fit. This would take pressure off of the physician’s and allow other’s their specialty. This would probably save money as the physician could concentrate on more acute illnesses and more minor or chronic situations could be seen by less expensive specialist. As for some of the comments that you tackled in your blog, someone needs to remind the physicians out there that not every infection is a highly contagious and rare disease, also that health care is about the person, not the title!

  5. bravo. I agree completely with you…. I am struck with terror with a NP or a PA comes into my examing room, My level of education is higher than theirs, i usually just force them to give me the medication i want! I believe that in most cases pharamcists actually teach the pharmacology part of Nursing and PA schooling, in essence i want to waork beside a gp that hands me a diagnosis and says here, give me the best therapy. after 6 years and 9 clinical rotations i think that we should be trusted by the healthcare community enough to know our stuff!

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

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

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

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

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

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

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

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

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

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

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

  10. It seems like this medical student has no idea about what Clinical pharmacists do or their field of study. I am a PharmD student (doctor of pharmacy) and I got my bachelor’s Degree in biochemistry from UCLA and went to pharmacy school for 4 years. Before I started pharmacy school, I thought I was going to learn about the drug names and their side effects and graduate to work at a retail store and make decent money. Well this idea totally changed after I started pharmacy school and I got to learn about the different disease states, diagnostic criteria, medications and monitoring parameters. What the medical student is talking about when he said can a pharmacist order CBC, Chem 14, PT/INR, lipid panel if a patient was started on a new medication. I would like to inform the medical student that the pharmacist in a hospital setting is the one monitoring heparin (so the pharmacist will order PTT) and will be the one monitoring Coumadin (so the pharmacist is the one ordering PT/INR) and the pharmacist is the one monitoring antibiotics such as Vancomycin, Tobramycin, Gentamycin ( so the pharmacist is the one who will be checking for microbial coverage, ordering the serum drug levels and altering the dose if needed using complex pharmacokinetic calculations). The pharmacist is the one who also monitors drug levels for drugs like phenytoin (and make adjustments based on albumin level and renal function), lithium, digoxin and methotrexate. Pharmacists in hospitals always conduct chart reviews and make recommendations to physicians regarding drug therapy management and antibiotics, they are the ones who alert physicians that they need to streamline the therapy or monitor the CBC and alert physicians if their patient is experiencing an adverse drug reaction (such as thrombocytopenia or anemia or leukopenia). Pharmacists in hospitals are the ones monitoring total parenteral nutrition (TPN) (in this case the pharmacist will be ordering CBC, CMP, and lipid panel to be able to monitor the patient’s renal and hepatic functions as well as monitoring the blood chemistry). The pharmacist knowledge and help is always under recognized because of the public’s and other healthcare providers’ lack of awareness about our education and training and what it enables us to do. The problem is that they look at the retail pharmacist and say they don’t know anything. Pharmacists in retail don’t use 20% of their knowledge, perhaps if they were allowed to practice their clinical knowledge which they spent 4 years training for in school the pharmacists you dealt with in retail would’ve been different. The other point about pharmacists don’t know anything about medications except for what the prescription reads for is so not true because if this is the case technicians can probably run the show in retail pharmacy, however it’s because pharmacists know more than what you think they know people’s lives are saved. For example a doctor wrote for tramadol for a patient with seizure history and on seizure medications and luckily for the patient that was caught by the pharmacist who gave a doctor a call to change it to Motrin. Of course that didn’t happen from the first call and the patient kept yelling at the pharmacist for not filling his medication because he was under a lot of pain. If the pharmacist had the authority to make changes then the pharmacist could’ve easily switched the medication to Motrin after checking with the patient to check if the patient has any contraindications to starting Motrin. The law doesn’t allow the pharmacist to alter a word written on a prescription. For example if a prescription for simvastatin reads “Take one tablet every day”. Although the pharmacist knows that if taken with food it can lower the bioavailability of the medication and reduce serum concentration of the drug, the pharmacist can’t alter the prescription and write “Take one tablet at bedtime”. Pharmacist can’t even change on PPI for another PPI if one isn’t covered by the insurance. When we say pharmacists should be given the right to write prescriptions or use their clinical judgement in refilling a patient’s prescription, we aren’t talking about diagnosing CHF or meningitis and we aren’t talking about refilling a patient’s prescription without ordering relevant labs. We are taking about easy things that were determined by the FDA to be easy enough for the public to diagnose and treat themselves for. For example if a patient used the lice medication over the counter with no relief, does that patient really need the medical expertise to determine that this patient’s head is full of lice. I think I can tell if someone has lice or not, this doesn’t need sophisticated diagnostic tools. The reason that those medications are kept in the pharmacy is due to their side effects which can be monitored by the pharmacist who is easier to be accessed by the public anyway. Has anyone tried to call a doctor and was actually connected to speak with him or her. If a patient is on blood pressure medications but otherwise healthy and has no other complains, can’t just the pharmacist take their blood pressure reading and refill or modify the therapy to help the patient achieve his or her goal. Can’t the pharmacist use the instant cholesterol check machine and refill the patient’s prescription or increase the dose to achieve the therapeutic goal. Does really a patient need to go to a doctor’s office to refill their Protonix prescription if they were previously diagnosed with GERD? DO you think the pharmacist can’t asses the patient to determine if the patient is controlled on the current medication or if they are worsening and refer them back to their physicians. Pharmacists are like all other health care providers have license and would never do anything they feel uncomfortable doing or do anything in which they were never trained in. The first rule is do no harm and the only reason we ask for flexibility is to help patients. We also want to help physicians and allow them to have more time to spend on those really in need of their expertise on complicated disease states requiring sophisticated diagnostic tools. Pharmacists in Florida are now given the right to prescribe for limited amount of medications and Canada also gave the right to pharmacist to do the same thing. Now let’s talk about you PA’s and NP’s they go to school for two years only, so a PA or a NP with 2 years of education are more qualified than a pharmacist to monitor a patient therapy. PA’s and NP’s can diagnose,deliver babies and write prescriptions, they can do about 80% of what physicians can do. So if in 2 years they gained all the knowledge needed to diagnose and prescribe a pharmacist in 4 years can’t even refill a maintenance medication for a patient. If a doctor started a patient on a blood pressure medication who is more qualified to monitor the progress of the patient and alter the therapy, would it be the PA or perhaps it could be more logical if we let the drug expert with 4 years of education do that. Would it make more sense to let the doctor, PA, and NP diagnose and let the pharmacist monitor and adjust therapy based on patient compliance, side effect profile, tolerability, allergies, other disease states, and drug interactions. The monitoring tools the medical student talked about is no magic, he probably just didn’t start his residency and didn’t deal with any clinical pharmacists yet. Doctor’s don’t have enough time to educate patients on diet and exercise and life style management, pharmacists do. There are a lot of data if you look up on the web or pubmed that show the benefits of adding a clinical pharmacist as part of the medical team. Doctors say they don’t trust pharmacists with monitoring the patient’s therapy. I really have a problem trying to understand this, we are the ones having the doctorate of pharmacy degree, we are the drug experts, and we are the ones who spend 4 years learning about medications and their side effects, adverse reactions and monitoring parameters so how come we are the ones that aren’t qualified to monitor the patients’ therapy. Doctors really need to get themselves educated about pharmacists’ education and their role in improving patient therapy outcomes in institutions such as Veteran’s affairs and kaiser. In these two settings patients schedule appointments to see their clinical pharmacists so that the pharmacist can monitor their drug therapy and make changes as needed. They have discovered how pharmacists can increase drug compliance, educate patients on their various disease states and reduce ER visits. Hopefully this will help educate the public about we do and what we can do.

  11. I am a pharmacist who works as a physician for more than ten years in a military hospital and I prescripe treatments and admit patients but I studied medicine theory and practice . fotunately everything passed as I wanted .

  12. I am proud with all things you mentioned .I AM PHARMACIST WHO works in military hospital for more than ten years my diagnosis for many diseases better than my collegues but I WANT to get DR DEGREE please tell me can I make in medicine or something like that I graduated 1983 from Germany GREISWALD university.

Leave a Reply

Your email address will not be published.