Pharmacists are better than us- bad press

[delco714]

https://www.berkshireeagle.com/stories/alan-chartock-i-publius-let-pharmacists-fill-void-left-by-doctor-shortage,550351

 

Paft shared on fb, I left my response there and emailed the publisher directly:

 

Hi there

 

Just got done reading your article on why pharmacists should prescribe.

 

Pharmacists are not medical providers. They aren't trained in diagnosis and treatment of diseases and managing comorbid conditions.

I don't want to perseverate the point.

 

Secondly this comment is out of line and warrants a redaction:

 

"Hey, if physician assistants and nurse practitioners can prescribe, it is nonsense not to give that right to pharmacists"

 

PA, which I'm one, and NP go through the same length or longer schooling credit and year-wise as pharmacists do.

 

The difference is PAs learn to be medical providers trained in the medical model, then graduate and continue to hone a craft in tandem with a more seasoned physician..eventually the PA catches up.. 5 + years (like a residency) and the PA-MD relationship often turns into more of a partnership.

 

That comment was condescending, vile, rude, and completely off the mark. I'd love to hear an educated explanation why you think that was ok. It was presented nonchalantly and immaturely. You could even say it was "nonsense".

 

Also, if the pharmacists want a bite out of my job, then they'll have to pay the sky high malpractice fees and open themselves to litigation just like we do. Oh, and they will probably have to go back to school for a few years and learn how to PRACTICE medicine.

 

Cheers!

[Kaepora]

This person very clearly does not understand the differences in training focus. 

[ProSpectre]

I just saw that as well. It appears to be written by a non-healthcare provider who doesn't really have a handle on the differences in training between a pharmacist and a medical practitioner.

Not only do they take a jab at PAs and NPs with the line you quoted, they erroneously claim that pharmacists train for 5 years, failing to mention that 4 years (8 semesters) is pretty standard and that there are quite a few 3 year programs as well. Furthermore, the focus of what they learn is much different, and they get no training in conducting thorough H&Ps, forming differentials, making diagnoses, reading EKGs or imaging, etc. 

I have a lot of respect for clinical pharmacists as they are a great resource, but the role simply isn't the same. But hey, what do we know, we're just well-meaning PAs "playing doctor". 

[EMEDPA]

there are a few PA/PharmD programs out there for folks who want to do both...

[Kaepora]

8 hours ago, ProSpectre said:

IFurthermore, the focus of what they learn is much different, and they get no training in conducting thorough H&Ps, forming differentials, making diagnoses, reading EKGs or imaging, etc. 

This.  Pharmacists participate in our interdisciplinary rounds, and while they are clearly the experts on all things pharmacology, it is also clear that they do not receive the same kind of training that NPs and PAs receive when it comes to H&Ps, Ddx, work-ups, and non-pharmacotherapy treatment modalities.  During rounds it's the APPs and physicians doing the vast majority of the talking, with the pharmacists chiming in for med related points.  It's just different, and this non-medical person doesn't know (what he doesn't know) - haha!

[Gordon, PA-C]

I can't take the author of the original article seriously when he looks like he's high on crank:

 

 

[mgriffiths]

I think this might be my favorite line: "As for the doctors, there is always the question of whether they have kept current on the various new medications."

In the beginning of the article the physician is the end-all-be-all, but with the above statement he is stating the pharmacists are better because they know the drugs better...I'm just slightly confused, but it's probably because I'm just a PA.  Let's ignore CME and that is is the physicians' job (as well as ours) to know the medications we prescribe.

[2234leej]

My wife is a clinical pharmacist at a hospital. I do believe that pharmacists are more than adequately trained to prescribe certain medications. There already are advanced practice pharmacists in California.

I do believe PAs and NPs have training that is superior when it comes to the diagnosis, management and treatment of medical conditions. Though, I think there is a place for pharmacists to provide certain medications in the retail clinics (what medications is a point of discussion). Even PTs prescribe basic musculoskeletal medications in the military and they have been doing so for the past 50 years as physician extenders. I don't see how pharmacy is different.

[mgriffiths]

I've never heard of PT prescribing any medications, but have heard of them recommending NSAIDs that can be bought over the counter.  But, that is VERY interesting if they are prescribing in the military.

As for pharmacists prescribing, you are correct that what they would be able to prescribe is VERY important, but the other side is are they actually going to have an office visit where they review all of the patient's medications and medical history (i.e. drug interactions, safe doses, kidney or liver disease, allergies, etc.)?  Patients rarely have a copy of their own updated medication list, I can only guess what the medication list looks like in a pharmacist's computer for patients with multiple problems whose medications are changed somewhat frequently.  As a PCP I struggle with maintaining up to date lists and my MA has to call specialists regularly - so how is a pharmacist going to confirm a patient's medication list before prescribing a medication?

[SoCal_PA]

Maybe we should involve the NPs on this one....They seem to have more pull than us 

[2234leej]

4 hours ago, mgriffiths said:

I've never heard of PT prescribing any medications, but have heard of them recommending NSAIDs that can be bought over the counter.  But, that is VERY interesting if they are prescribing in the military.

As for pharmacists prescribing, you are correct that what they would be able to prescribe is VERY important, but the other side is are they actually going to have an office visit where they review all of the patient's medications and medical history (i.e. drug interactions, safe doses, kidney or liver disease, allergies, etc.)?  Patients rarely have a copy of their own updated medication list, I can only guess what the medication list looks like in a pharmacist's computer for patients with multiple problems whose medications are changed somewhat frequently.  As a PCP I struggle with maintaining up to date lists and my MA has to call specialists regularly - so how is a pharmacist going to confirm a patient's medication list before prescribing a medication?

PTs have been prescribing basic musculoskeletal medications for a long time in the military (basic NSAIDs, stronger dose NSAIDs, muscle relaxers, etc.). They can also order imaging and order labs. It makes sense, as they see patients often for a variety of different orthopedic issues. Civilian PTs cannot. The ones in the military have to be board-certified and take a military course to prescribe.

[Joelseff]

Yeah because we all know practicing medicine is just like, you now seeing a pt, having "Doctor" in your name and like, you know writing up meds and $#!+... Anybody with Google can like, do it you know...

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[sas5814]

The magic sauce is everyone working at the top of their game. That, however doesn't mean fantastic and possibly dangerous encroachments into areas you aren't qualified for.

Do pharmacists know more about pharmacology than most PAs? I certainly hope so. Does that qualify them to prescribe? No no no no.

I served for several years on the BOD of a hospital district and chaired the board credentials committee...the last stop of the credentials process. The number of times I had to get into arguments over who could do what, usually provoked by one physician group trying to protect their financial interests, I can't even count. My questions were simple. Are the measurably, properly trained and qualified? Can they do it to a high degree of excellence? Is there a system to ensure ongoing competence?

An example was the ortho docs not wanting the pods to operate on the ankle. That argument went on for months until I applied the above questions. The answers were yes, yes, and yes. Problem solved.

[sk732]

Canadian military PT weren't allowed to prescribe when I left...US obviously different.

I love having a clinical pharmacist in my ER - infinitely smarter than me, especially when it comes to drug/drug stuff, dosing and such (and simply just smarter than me, full stop).  I well remember the clown that was the Director Pharm Services for the Canadian Forces at one time was a pioneer in pharmacist chronic disease management, but honestly, if he had his way, only pharmacists would be allowed to prescribe...even though they aren't trained in those little nuances of what makes looking after someone the practice of medicine.  I met the guy during an inspection one time (one of my medic specialties was pharm tech/medical supply specialist) - his ego had it's own entourage - and we had a discussion about why a medic couldn't/shouldn't carry and administer a morphine auto-injector in a combat situation, yet we could prescribe an infantry officer the same thing for their own use...apparently an infantry officer can follow a protocol better than a trained medic was what it came down to (insert eye rolling emoji).

He also set the OTC and Rx Pharmaceutical Exam for medics and PA's - when the PA Rx package came out, the Medical Director for the PA training Cell absolutely lost it, as this guy was examining people on drugs that weren't even licensed for use in Canada OR the US, much less in the CAF at the time - it was designed so that nobody would pass...again he was drinking his own "only pharmacists should prescribe" Kool Aid.  

We all have our lanes and we all need to stay in them for things to work properly - someone thinks they're the only one on the road.

SK

[AdamPAC]

I believe there was already a bill passed allowing this in Colorado earlier this year. Of course it is a limited scope that the pharmacist must operate under.

House Bill 18-1313, which looks like it just expands prescriptive authority to include the following:

Universal Citation: CO Rev Stat § 12-42.5-601 (2017)

As used in this part 6:

(1) (a) "Collaborative pharmacy practice agreement" means a written and signed agreement entered into voluntarily between one or more pharmacists licensed pursuant to this article and one or more physicians or advanced practice nurses licensed in this state, which statement grants authority to the pharmacist or pharmacists to provide evidence-based health care services to one or more patients pursuant to a specific treatment protocol delegated to a pharmacist or pharmacists by the physician or advanced practice nurse.

(b) A "collaborative pharmacy practice agreement" may also mean a statewide drug therapy protocol developed by the board, the Colorado medical board, and the state board of nursing in collaboration with the department of public health and environment for public health care services.

Where before, according to how I read the House Bill, their prescriptive authority was specifically for OTC, and under the sponsorship of a state-run benefits program only.

I am still a student, and don't practice yet, but I imagine that even with this limited amount of latitude in prescriptive authority there is plenty of room for error. The bill is below. I am no lawyer, but the language looks vague enough that a pharmacist could be delegated patient visits by a physician, and that pharmacist could 1. evaluate, 2. diagnose, and then 3. prescribe drugs according to a state protocol. Maybe I misread this, like I said, I am no lawyer. However, the potentially dangerous part is with that 2nd task. 

HOUSE BILL 18-1313

BY REPRESENTATIVE(S) Ginal and Becker J., Winkler;
also SENATOR(S) Aguilar and Priola, Crowder, Fields, Gardner, Jahn, Kefalas, Marble, Merrifield, Tate, Todd, Zenzinger.

CONCERNING THE ALLOWANCE OF A PHARMACIST TO SERVE AS A PRACTITIONER UNDER CERTAIN CIRCUMSTANCES.

Be it enacted by the General Assembly of the State of Colorado:

SECTION 1. In Colorado Revised Statutes, 12-42.5-102, amendthe introductory portion, (27), and (32) as follows:

12-42.5-102. Definitions. As used in this article 42.5, unless the context otherwise requires or the term is otherwise defined in another part of this article 42.5:

(27) "Pharmaceutical care" means the provision of drug therapy and other pharmaceutical patient care services by a pharmacist intended to achieve outcomes related to the cure or prevention of a disease, elimination or reduction of a patient's symptoms, or arresting or slowing of a disease process. In addition to the preparation, dispensing, and distribution of medications, "pharmaceutical care" may include assessment and evaluation of the patient's medication-related needs and development and communication of a therapeutic plan with defined outcomes in consultation with the patient and the patient's other health care professionals to attain the desired outcome. This function includes efforts to prevent, detect, and resolve medication-related problems for individual patients. "Pharmaceutical care" does not include prescriptive authority; except that a pharmacist may prescribe only over-the-counter medications to a recipient under the "Colorado Medical Assistance Act" as authorized pursuant to section 25.5-5-322 C.R.S. OR PURSUANT TO A COLLABORATIVE PHARMACY PRACTICE AGREEMENT AS DEFINED IN SECTION 12-42.5-601 (1)(b).

(32) "Practitioner" means a person authorized by law to prescribe any drug or device, acting within the scope of such authority, INCLUDING A PHARMACIST WHO IS PARTICIPATING WITHIN THE PARAMETERS OF A STATEWIDE DRUG THERAPY PROTOCOL PURSUANT TO A COLLABORATIVE PHARMACY PRACTICE AGREEMENT AS DEFINED IN SECTION 12-42.5-601 (1)(b), OR PRESCRIBING OVER-THE-COUNTER MEDICATIONS PURSUANT TO SECTION 25.5-5-322.

 

[vb315]

3 hours ago, AdamPAS said:

 

Universal Citation: CO Rev Stat § 12-42.5-601 (2017)

As used in this part 6:

(1) (a) "Collaborative pharmacy practice agreement" means a written and signed agreement entered into voluntarily between one or more pharmacists licensed pursuant to this article and one or more physicians or advanced practice nurses licensed in this state, which statement grants authority to the pharmacist or pharmacists to provide evidence-based health care services to one or more patients pursuant to a specific treatment protocol delegated to a pharmacist or pharmacists by the physician or advanced practice nurse.

(b) A "collaborative pharmacy practice agreement" may also mean a statewide drug therapy protocol developed by the board, the Colorado medical board, and the state board of nursing in collaboration with the department of public health and environment for public health care services.

How long until NPs are the collaborating docs for PAs and delegate to them to practice medicine? (They are doctors after all)

[EMEDPA]

some places let pharmacists do limited prescribing for things like birth control, vaccinations, etc. I think I am ok with that. 

[ak004]

I don’t know the specifics or differences in education, but I know that pharmacists in European countries can dispense more medications (like antibiotics) than their American counterparts. You tell them what’s going on (symptoms of a UTI or yeast infection) and they’ll give you medication without a prescription

[Joelseff]

Can pharmacists i&d? Suture? Interpret labs, ecg, imaging etc? Do they know what to do next with test results (POS and neg)? Do they have the clinical training and background to know big sick from little sick? There's more to Medicine than just.. Well.. "medicine."

 

If it's just for minute clinics where "everyone gets an RX for a sx" then what will NPs do? (lol tongue in cheek. Relax Francis) lol

 

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[Joelseff]

How long until NPs are the collaborating docs for PAs and delegate to them to practice medicine? (They are doctors after all)

Scary but it's prob gonna happen. Hope to be on my way out by then though...or I will find something else to do if it comes to that $#!+show...

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[delco714]

Scary but it's prob gonna happen. Hope to be on my way out by then though...or I will find something else to do if it comes to that $#!+show...

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I suggest working for malpractice attorneys doing chart reviews at that junction :)

[2234leej]

On ‎9‎/‎19‎/‎2018 at 9:31 PM, EMEDPA said:

some places let pharmacists do limited prescribing for things like birth control, vaccinations, etc. I think I am ok with that. 

agreed. I don't see this as an issue at all.

[Kaepora]

On 9/19/2018 at 10:31 PM, EMEDPA said:

some places let pharmacists do limited prescribing for things like birth control, vaccinations, etc. I think I am ok with that. 

I guess.  No medication is innocuous.  Although, I'm assuming there is a medically directed algorithm or checklist in place for identifying patients for which a certain med is contraindicated.  Like for birth control: History of thrombophlebitis or coagulopathy/inherited disorder of coagulation, cerebro-vascular or coronary artery disease, estrogen-dependent neoplasias, smoking, HTN, impaired hepatic/renal function, etc.

It is what it is.  Everyone is vying for a piece of the pie.

[delco714]

I guess.  No medication is innocuous.  Although, I'm assuming there is a medically directed algorithm or checklist in place for identifying patients for which a certain med is contraindicated.  Like for birth control: History of thrombophlebitis or coagulopathy/inherited disorder of coagulation, cerebro-vascular or coronary artery disease, estrogen-dependent neoplasias, smoking, HTN, impaired hepatic/renal function, etc.
It is what it is.  Everyone is vying for a piece of the pie.

Then they have to see the fibro, ic, restless leg..etc etc too

[Kaepora]

3 hours ago, delco714 said:

On 9/22/2018 at 9:40 PM, Kaepora said:

I guess.  No medication is innocuous.  Although, I'm assuming there is a medically directed algorithm or checklist in place for identifying patients for which a certain med is contraindicated.  Like for birth control: History of thrombophlebitis or coagulopathy/inherited disorder of coagulation, cerebro-vascular or coronary artery disease, estrogen-dependent neoplasias, smoking, HTN, impaired hepatic/renal function, etc.
It is what it is.  Everyone is vying for a piece of the pie.

Then they have to see the fibro, ic, restless leg..etc etc too

Haha, they can have *all* the fibro patients.  And IBS.