Why I'm Against Pharmacist Prescribing
Wednesday, February 24, 2010
Every year or so, some Pharmacy organisation rears its head and suggests Pharmacists be able to prescribe medications. Schedule 4 medications are the realm of the doctors. Pharmacists can't prescribe them now, and nor should they.
Of course, pharmacists are already entrusted with the responsibility of monitoring access and assessing suitability of certain medications; the "Schedule 3s". As a cohort, we can give out appropriate thrush creams, morning-after-pills and asthma relievers, and we're generally pretty good at it. Often our ability to assess the need for pain medication or sedating antihistamines is overwhelmed by apathy or the desire for profit.
Whilst I'll deal with profits opposing ethical prescribing later, the key point is that pharmacists are limited in their diagnostic powers. We don't take long, effusive, thorough histories. Not only is there not enough time in a community pharmacy, but pharmacists are simply not trained in the process. It takes several years of medical school just to refine this strength, let alone remember all the pharmacology, indications and interactions. As the Dean said on my first day of Pharmacy School "Where doctors are the doyens of diagnosis, we are the masters of medicine"; a philosophy I'm still well agreed with.
There is a suggestion that an increased knowledge base and Continuing Professional Education (CPE) strengthens the case for pharmacist prescribing. Rather than establish a new-found ability to select and initiate medicines, CPE strives to further inform pharmacists about options for treatment without establishing which medicine is prefereable for each individual patient. That decision requires a full history and physical exam.
Even in hospitals, where the most book-smart pharmacists hang out, there are rarely opportunities to initiate therapy. Specialist physicians are substantially better equipped to make these decisions, and not necessarily through their qualification. Hospital pharmacists play an essential role on the wards; checking charts and modifying therapies. I've not seen a pharmacist saunter up to a physician and say, "You know what, Mrs. Jones has been hypertensive and tachycardic for a while, I think you should give her some atenolol." It's just too much of a leap of faith, without acres of physiology, pathology and pathophysiology.
Don't get me wrong, both physiology and pathology are taught in Pharmacy school, but not, I believe, at a level even close to what's required to diagnose or initiate medication.
In recent years, some Pharmacists have undergone further training and assessment to become accredited to perform additional roles; rural and remote Pharmacists have an extended scope of practice compared with their metropolitan colleagues. Usually there's also a close relationship with a local doctor and as seems to be the way out bush, there's a strong emphasis on health outcomes, not profits or convenience.
Comparatively, Home Medication Reviews (HMRs) are a good way of reviewing patients on thirty or more medications, streamlining their dosing regimen and spying on exactly how much a patient or couple push the SafetyNet 20 Day rule. Most of the reports that have wandered across my path are blowing smoke, often created from preconceived templates and noting obvious interactions that would have flashed up on the prescriber's software at the moment of prescription. Sure, they can point out the odd interaction and help educate the patient about which over-the-counter products to avoid. But that remains the community pharmacist's job; they don't claim $140 a pop for each batch of suggestions.
The Pharmaceutical Benefits Scheme (PBS), through regular reviews, has also begun the establishment of 11 month repeat 'scripts for some medications. This means that the prescriber doesn't have to be writing 'scripts every five seconds for a medication that's unlikely to change in dose, frequency and is well tolerated. But, they still need to review it yearly and the medicine is still doctor-initiated. This aspect is most likely to garner public support; "I always have to see the Doc for my sleepers", "I can never get in to see Dr Bob." The PBS appropriately limits the number of repeats based on clinical indications and recommended treatment courses, with an eye to reducing medication wastage.
In a recent report in The Australian, the Pharmaceutical Society of Australia (PSA) campaigns for pharmacist prescribing. The article also notes that the PSA represents 75% of pharmacists in Australia. I'm not one, having resigned my membership in 2007. I have, however, done some polling - enough for a half-decent binomial distribution - and there's no way the vast majority of pharmacists would initiate medications for chronic diseases. At present they're not comfortable writing "sick day" certificates; you can't even cause much harm with those.
Thankfully, most pharmacists appear well aware of their limitations. This most recent push again appears cast from the ivory-tower of pharmacy advocacy without a mind to the majority of the workforce in everyday community pharmacy practice.
The article continues, "PSA national president Warwick Plunkett said a basic requirement would be that the pharmacist dispensing the drugs could not also have prescribed them, to remove the danger that some might seek to profit from their own scripts."
Thanks Captain Obvious. Unfortunately, Mr Plunkett neglects to mention the marked benefits of running a larger pharmacy with two pharmacists on duty; they would be able fill their own store's prescriptions whilst the one-pharmacist strip-mall stores would not. The comment is intended to give the appearance of balance and ethics, when in fact it panders to large banner groups and shuns smaller, independent pharmacists.
The PSA is clearly biting the hand that feeds; it seems a corresponding retort was issued by the Australian Medical Association (AMA) just a few days later, suggesting it should be Doctors running the Pharmacy show. Everyone just needs to calm down.
Although pharmacists know about medicines and some common minor ailments, we're not qualified to diagnose illness nor initiate medications that fall beyond our scope of practice. Most diseases, particularly chronic illnesses, fall beyond the pharmacist's scope of practice. Moreover, allowing pharmacists to prescribe removes a key ethical and quality-control barrier; there's no way the notion could lead to better health outcomes. Pharmacists shouldn't prescribe schedule 4 medications. Most of us are well aware of our clinical limitations; the folks making national media press releases are an exception.
Of course, pharmacists are already entrusted with the responsibility of monitoring access and assessing suitability of certain medications; the "Schedule 3s". As a cohort, we can give out appropriate thrush creams, morning-after-pills and asthma relievers, and we're generally pretty good at it. Often our ability to assess the need for pain medication or sedating antihistamines is overwhelmed by apathy or the desire for profit.
Whilst I'll deal with profits opposing ethical prescribing later, the key point is that pharmacists are limited in their diagnostic powers. We don't take long, effusive, thorough histories. Not only is there not enough time in a community pharmacy, but pharmacists are simply not trained in the process. It takes several years of medical school just to refine this strength, let alone remember all the pharmacology, indications and interactions. As the Dean said on my first day of Pharmacy School "Where doctors are the doyens of diagnosis, we are the masters of medicine"; a philosophy I'm still well agreed with.
There is a suggestion that an increased knowledge base and Continuing Professional Education (CPE) strengthens the case for pharmacist prescribing. Rather than establish a new-found ability to select and initiate medicines, CPE strives to further inform pharmacists about options for treatment without establishing which medicine is prefereable for each individual patient. That decision requires a full history and physical exam.
Even in hospitals, where the most book-smart pharmacists hang out, there are rarely opportunities to initiate therapy. Specialist physicians are substantially better equipped to make these decisions, and not necessarily through their qualification. Hospital pharmacists play an essential role on the wards; checking charts and modifying therapies. I've not seen a pharmacist saunter up to a physician and say, "You know what, Mrs. Jones has been hypertensive and tachycardic for a while, I think you should give her some atenolol." It's just too much of a leap of faith, without acres of physiology, pathology and pathophysiology.
Don't get me wrong, both physiology and pathology are taught in Pharmacy school, but not, I believe, at a level even close to what's required to diagnose or initiate medication.
In recent years, some Pharmacists have undergone further training and assessment to become accredited to perform additional roles; rural and remote Pharmacists have an extended scope of practice compared with their metropolitan colleagues. Usually there's also a close relationship with a local doctor and as seems to be the way out bush, there's a strong emphasis on health outcomes, not profits or convenience.
Comparatively, Home Medication Reviews (HMRs) are a good way of reviewing patients on thirty or more medications, streamlining their dosing regimen and spying on exactly how much a patient or couple push the SafetyNet 20 Day rule. Most of the reports that have wandered across my path are blowing smoke, often created from preconceived templates and noting obvious interactions that would have flashed up on the prescriber's software at the moment of prescription. Sure, they can point out the odd interaction and help educate the patient about which over-the-counter products to avoid. But that remains the community pharmacist's job; they don't claim $140 a pop for each batch of suggestions.
The Pharmaceutical Benefits Scheme (PBS), through regular reviews, has also begun the establishment of 11 month repeat 'scripts for some medications. This means that the prescriber doesn't have to be writing 'scripts every five seconds for a medication that's unlikely to change in dose, frequency and is well tolerated. But, they still need to review it yearly and the medicine is still doctor-initiated. This aspect is most likely to garner public support; "I always have to see the Doc for my sleepers", "I can never get in to see Dr Bob." The PBS appropriately limits the number of repeats based on clinical indications and recommended treatment courses, with an eye to reducing medication wastage.
In a recent report in The Australian, the Pharmaceutical Society of Australia (PSA) campaigns for pharmacist prescribing. The article also notes that the PSA represents 75% of pharmacists in Australia. I'm not one, having resigned my membership in 2007. I have, however, done some polling - enough for a half-decent binomial distribution - and there's no way the vast majority of pharmacists would initiate medications for chronic diseases. At present they're not comfortable writing "sick day" certificates; you can't even cause much harm with those.
Thankfully, most pharmacists appear well aware of their limitations. This most recent push again appears cast from the ivory-tower of pharmacy advocacy without a mind to the majority of the workforce in everyday community pharmacy practice.
The article continues, "PSA national president Warwick Plunkett said a basic requirement would be that the pharmacist dispensing the drugs could not also have prescribed them, to remove the danger that some might seek to profit from their own scripts."
Thanks Captain Obvious. Unfortunately, Mr Plunkett neglects to mention the marked benefits of running a larger pharmacy with two pharmacists on duty; they would be able fill their own store's prescriptions whilst the one-pharmacist strip-mall stores would not. The comment is intended to give the appearance of balance and ethics, when in fact it panders to large banner groups and shuns smaller, independent pharmacists.
The PSA is clearly biting the hand that feeds; it seems a corresponding retort was issued by the Australian Medical Association (AMA) just a few days later, suggesting it should be Doctors running the Pharmacy show. Everyone just needs to calm down.
Although pharmacists know about medicines and some common minor ailments, we're not qualified to diagnose illness nor initiate medications that fall beyond our scope of practice. Most diseases, particularly chronic illnesses, fall beyond the pharmacist's scope of practice. Moreover, allowing pharmacists to prescribe removes a key ethical and quality-control barrier; there's no way the notion could lead to better health outcomes. Pharmacists shouldn't prescribe schedule 4 medications. Most of us are well aware of our clinical limitations; the folks making national media press releases are an exception.
