The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Monday, April 16, 2007

The Pharmacists Aren't Perfect, Either

I've been thinking a lot about this new law allowing pharmacists limited rights to prescribe and change treatment plans in Alberta. Now generally, I think pharmacists rock. When I'm managing inpatients I often rely on the expertise of the hospital pharmacist, who thankfully is just a phone call away and is always happy to answer my questions. In the academic practice where I've been working for nearly two mind-numbing months, we have a full-time pharmacist available who also does incredibly helpful things like scan databases of patients to make suggestions on the optimization of their medical management for certain conditions. In the community, the pharmacists (for the most part) are happy to repeatedly save the ass of the new doc in town (that would be me), faxing back to politely remind me that I've neglected to include the limited use code for an elderly patient's meds, or to tell me for the third time that I can't order 5mg of Flexeril qhs because the lowest dose of Flexeril available is 10mg (regardless of what Lexi-Drugs tells me). Then again, these pharmacists who seem so patient with my rookie mistakes may be the same ones who then turn around and refer to me as an idiot who doesn't take the time to talk to my patients (as per The Angry Pharmacist).

Not long ago I had an entire family come into my community family practice-- both 30-something parents and two sons just shy of puberty. Mom was clearly unwell. She leaned on her husband for support, and complained of a sudden onset of high fever, joint and muscle aches, extreme exhaustion, headache and cough. A few more questions and a physical exam later, I diagnosed influenza. It was actually quite classic. I took a naso-pharyngeal swab to send to public health, and sat down with the family to discuss their concerns. Most of all, the parents were concerned that their two children would get this as well. None had been vaccinated, and the severity of this illness surprised both of them-- they had thought that the flu was a bad cold, and mom in particular was shocked by how debilitated she had been.

We discussed indications for treatment for mom (and decided against starting treatment based on the duration of symptoms) as well as indications for prophylaxis for the rest of the family. The parents felt strongly that they didn't want their children to suffer from the same symptoms as mom, and decided to give both children prophylaxis. We discussed the risks and benefits, weighed both boys and calculated their dosage.

I saw the father with similar flu symptoms about a week later. I asked if the children had been treated. They hadn't. Apparently, when the father had taken the script to the pharmacy, the pharmacist told him that there was no point in taking the meds before the kids got symptoms, and that he'd be better off leaving the script at the pharmacy to be filled when the kids got sick. So that's what he did.

Except that's totally not the case. The doses for prophylaxis of influenza (to avoid a full-blown case of flu in someone who has been recently exposed to a confirmed case) is not the same as the dose for treatment of a full-blown case of flu. If the father had followed the pharmacist's instructions, the flu wouldn't have been prevented and the dose prescribed wouldn't have been enough to adequately treat it if taken after the kids became symptomatic.

Now this error wasn't life threatening. And because there is a certain degree of the broken telephone game, I can't be certain what exactly was said in the exchange between the father and the pharmacist (another fact I believe The Angry Pharmacist forgets all too often). But it worries me that a pharmacist would seemingly take it into his own hands to change a treatment plan that was decided between myself and my patient with only a partial understanding of the situation.

If pharmacists were allowed to prescribe, wouldn't this scenario happen more often? And potentially with more severe consequences?

N.B. Please accept my usual disclaimer that I have absolutely nothing against pharmacists as a whole, and actually find the great majority to be an invaluable source of both clinical and practical information. And can drink me under the table.

25 Comments:

Blogger A girl said...

Well written, Couz. I think the whole issue here is that of safety and potential additional benefits from prescribed meds.
Who is in better position to provide safest and most beneficial drugs regimes to the patients? Pharmacists who know nothing about the patient except for his/hers meds or docs who know the whole story? I think a discussion should happen before any changes in treatments are made. Changing, refusing to fill, or prescribing meds by pharmacists without a consult with treating physician can potentially be a disaster. Although many patients are well aware why this or that medication was prescribed, some are walking out of the office with limited insight. Plus, as you said, there are multiple misunderstandings that happen on daily basis between care providers and patients. Be it pharmacist, physician, or whoever. So we have a situation when a messenger delivers an incorrect message to the other end of the line and decisions are made based on false information. In this case it was not lethal, in others it may be...
Plus the choice of the drug is often guided by side effects and off label benefits. SSRIs are perfect example. OCPs also come to mind. Pharmacist may not know the whole story and the patient may (rightly so) not willing to disclose the whole information. So I am weary about the whole idea of pharmacists taking more active role in this. Although, I do appreciate their help a lot. When I was on the wards, doing Internal, I used their expertise daily. There we had time to sit down and go through a case, so we can figure out the best possible treatment. A little different situation from a broken telephone scenario…

9:33 PM

 
Blogger Wyatt said...

Wow, fascinating story! I'd be pissed if a pharmacist overrode my prescription without talking to me about it first. In what situation is it proposed to be useful for pharmacists to have prescribing power? As docs we hardly ever prescribe a new medication without an office visit first that should include a review of the history and a physical examination. If there was a very clinically involved pharmacist working closely with a physician I could possibly see it, but that seems to be pretty rare.

12:20 AM

 
Anonymous Jen said...

We had a presentation in a first year nursing class back in 2003 in alberta from a pharmacist on this very issue. At the time he was talking about things like plantar warts, eczema, and under-the-counter drugs etc. that people already routinely come in for that are easily describable by the patient. Needless to say he won over a bunch of first year nursing students but we didn;t know our aspirin from our enalapril. I doubt he'd get the same reaction just a few short years later... even without stories like you describe couz

5:09 PM

 
Blogger Midwife with a Knife said...

Hear Hear!!

9:51 PM

 
Anonymous Anonymous said...

So what exactly are they allowed to prescribe? Give it to me in lay person's terms.

12:49 AM

 
Anonymous Anonymous said...

excuse me, I hate to be a party-pooper, but how many courses have YOU taken in pharmacology, Miss Anonymous Docteuse? Probably not more than one or two.

I have no idea whether it will be good or bad to let pharmacists prescribe. I do know that it will likely reduce doctor loads and thus total medical costs. Seems like an experiment worth running without you going off on a turf war/ protectionist guild hissy fit.

3:20 PM

 
Anonymous Anonymous said...

Good god. Her post couldn't have been further from a hissy fit turf war. Someone is obviously getting defensive...

3:34 PM

 
Blogger Reserved Stipulation said...

As a patient, the only time I want my pharmacists (they all ROCK) to interject with what my doctor has prescrobed is if the new medication will interfere with the stuff I'm already taking.

However, if a pharmacist will see me for a skin rash or something easily treatable without a copay, then I'll gladly see them.

3:59 PM

 
Blogger med neophyte said...

I don't have a fully formed opinion on whether or not pharmacists should have the power to perscribe. I don't know enough about it or how far their perscription powers go.

But I think that assuming this strategy will necessarily halt rising health costs is a mistake. It may or may not. Physician fees are a relatively minor part of rising costs, whereas the increased use and costs of medications are huge. Therefore the rise in costs has more to due with perscribing strategies rather than who is doing the perscribing. It won't take long for the drug companies to start targeting pharmacists (just as they do doctors) to use more and more expensive medications if they have the power to perscribe them, with the added conflict of interest that the pharmacist is also selling them.

4:11 PM

 
Anonymous Anonymous said...

A lot of what pharmacists are interested in is not necessarily prescribing authority. However, collaborative practice agreements are crucial for effective disease state management, a task to which pharmacists are ideally suited. Pharmacists want to work WITH physicians in the management of hypertension, dyslipidemia, anticoag, and etc. Pharmacists are truly drug experts and are far too often underutilized in the U.S. healthcare system. We have much potential beyond just dispensing. I'm not up to date on Alberta's pharmacy situation, but I can say that U.S. pharmacists are not particularly interested in blanket prescriptive authority.
-The Optimistic Pharmacy Student

9:23 PM

 
Anonymous Anonymous said...

Pharms should be allowed to give meds for UTI. That is my opinion!

Macnic

10:11 AM

 
Blogger Couz said...

Gah. I've seen enough misdiagnosed (usually with no exam) "UTI's" that were actually first episode genital herpes outbreaks that I don't think that would be a great idea.

12:23 PM

 
Anonymous AB Tech said...

Alberta pharmacists, at this point, can "adapt" a prescription..which means they can make some changes to the original Rx (ie. if one item isn't covered, which doctors can not be expected to memorize what is covered under every plan but it would be nice if they could remember that Fucithalmic is not a benefit for most clients, they can make a reasonable substitution, like when they know the doctor will change the Rx to Garamycin instead, they can "adapt" it). All adaptations must be documented and the doctor notified.

The pharmacist can write an "emergency rx". Mr. Smith has run out of his Ventolin and his doctor is unavailable to authorize a refill, the pharmacist may authorize one more refill and notify the doctor of this. However, the pharmacist that prescribes this "emergency rx" can not be the pharmacist who fills the rx.

Pharmacists can not write Rx's for narcotics or controlled drugs, including benzos. Pharmacists, at this point, can not initiate therapy. Later on, a pharmacist who is a clinical specialist in something like Asthma, can initiate therapy and consult with the doctor or refer the patient to other health care professionals. The primary doctor still needs to be advised of any initiation or referals. They will be able to prescribe within their scope of practice. If it's an allergic reaction, they can prescribe hydroxyzine instead of giving the OTC diphenhydramine.

Pharmacists in Alberta will have access to patient lab results and patient records through Alberta Netcare.

I guess what I'm really trying to say is that it's not like Pharmacists are going to be running the show, it's more of a complimentary service, which incidentally, they are either currently doing for FREE or the patient has to pay out of their pocket for the services as it's not covered under drug plans.

3:20 PM

 
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9:28 AM

 
Anonymous Anonymous said...

Flexeril 5 mg is commercially available in the US, but maybe not in Canada. However, your pharmacist should be introduced to a wonderful little tool called a pill-splitter.

I don't think that pharmacists should be able to prescribe independently, unless it's on a really restricted basis. A one time refill because the doctor isn't calling back and the patient has been taking atenolol for 10 years? Sure. Diagnose a rash? Nope. We don't take any form of diagnostic class in school, not even with the fancy new Doctor of Pharmacy degree we're all required to have now (in the US, at least). I couldn't tell the difference between a fungal rash that needs some clotrimazole and eczema that needs triamcinolone. I don't want to deal with it. But when someone comes to me coughing and wheezing and there are no refills on the albuterol, I want to be able to authorize a refill.

7:09 PM

 
Blogger medstudentitis said...

Unless a pharmacist is going to do a urine dip and culture I don't think they should be able to prescribe for UTIs. Just my two cents.

2:11 PM

 
Anonymous Anonymous said...

Do you mind if I ask what you said to the patient when he told you what had happened? I'm not sure how I'd handle that with a patient.. and at what point is it necessary to contact the pharmacist directly to discuss the issue? As you said, in this case fortunately it wasn't an issue that resulted in dire consequences, but one can imagine scenarios where it might.

7:34 PM

 
Anonymous Anonymous said...

Pharmacist will have patients records available? Now, I know this means that techs and everyone else working in that store will also be looking at patients records. How is this a good thing?

11:14 PM

 
Anonymous Anonymous said...

RE: UTI, if you've had one, you totally know what it feels like. I've suffered hours in the ER on Thanksgiving and at 3am just to get the drugs that make you stop feeling like peeing all the time. I dunno why a pharmacist can't just give me one pill and send me to the WIC the next day?

Macnic

11:56 AM

 
Anonymous AB Tech said...

"Now, I know this means that techs and everyone else working in that store will also be looking at patients records."

Honestly, do you think we have a big party in the pharmacy and flip through patient records?! In Alberta, the patient EHR is highly protected, only accessed by pharmacists with user specific key fobs for credentials over a very secure network.

While I do agree that if you've suffered a UTI that you know it when you have it, I don't agree that pharmacists will be prescribing for that unless they are able to do a culture. And I have never mis-diagnosed myself when I've had to go to the doctor for a UTI...I've always been correct.

I've always thought that the perfect scenario would be a doctor diagnosing and having the pharmacist prescribe in collaboration (no offense to the doctors).

4:00 PM

 
Anonymous Anonymous said...

As a pharmacist, I don't particularly want to prescribe medications for anyone, even for myself--I'm apt to have the worst thing imaginable with a few extra symptoms, but I do love a good collaboration with the doc. When I have a legitimate medical concern, I don't like being fobbed off to the receptionist though, when they are allowed to pretend over the phone that they're the physician's right arm. If I'd been in the situation with the flu prophy, I'd have called the doc, if I saw need to question the script. Perhaps, that day the pharmacist had one too many secretaries call in refills for Vicodin and was thinking that the physician was not really acting in the patients' best interest. Just a thought. When I pull retail shifts, I do see and hear a lot of things, that my training has prepared me to offer a suggestion e.g. sorry we don't carry any antibiotics not obtainable without a prescription...please, see the doctor right away--you don't want to lose your sight, or yes, it's likely that's athlete's foot, but if it involves the nail, the products we carry require weeks and weeks of diligent therapy and it's better that you save time and get the correct diagnosis and a shorter treatment course. I have seen evidence of physicians who are so specialized that they know nothing out of their field of expertise. The more interaction with the patient and prescriber, the more knowledge to learn from. From a pharmcist's perspective, ten years after graduation, I went for PharmD, and the med students we studied and worked with were eager for my input, as well as older docs at the job site.

11:40 PM

 
Anonymous Anonymous said...

As a pharmacist, I don't particularly want to prescribe medications for anyone, even for myself--I'm apt to have the worst thing imaginable with a few extra symptoms, but I do love a good collaboration with the doc. When I have a legitimate medical concern, I don't like being fobbed off to the receptionist though, when they are allowed to pretend over the phone that they're the physician's right arm. If I'd been in the situation with the flu prophy, I'd have called the doc, if I saw need to question the script. Perhaps, that day the pharmacist had one too many secretaries call in refills for Vicodin and was thinking that the physician was not really acting in the patients' best interest. Just a thought. When I pull retail shifts, I do see and hear a lot of things, that my training has prepared me to offer a suggestion e.g. sorry we don't carry any antibiotics not obtainable without a prescription...please, see the doctor right away--you don't want to lose your sight, or yes, it's likely that's athlete's foot, but if it involves the nail, the products we carry require weeks and weeks of diligent therapy and it's better that you save time and get the correct diagnosis and a shorter treatment course. I have seen evidence of physicians who are so specialized that they know nothing out of their field of expertise. The more interaction with the patient and prescriber, the more knowledge to learn from. From a pharmcist's perspective, ten years after graduation, I went for PharmD, and the med students we studied and worked with were eager for my input, as well as older docs at the job site.

11:41 PM

 
Anonymous Anonymous said...

As a pharmacist, I don't particularly want to prescribe medications for anyone, even for myself--I'm apt to have the worst thing imaginable with a few extra symptoms, but I do love a good collaboration with the doc. When I have a legitimate medical concern, I don't like being fobbed off to the receptionist though, when they are allowed to pretend over the phone that they're the physician's right arm. If I'd been in the situation with the flu prophy, I'd have called the doc, if I saw need to question the script. Perhaps, that day the pharmacist had one too many secretaries call in refills for Vicodin and was thinking that the physician was not really acting in the patients' best interest. Just a thought. When I pull retail shifts, I do see and hear a lot of things, that my training has prepared me to offer a suggestion e.g. sorry we don't carry any antibiotics not obtainable without a prescription...please, see the doctor right away--you don't want to lose your sight, or yes, it's likely that's athlete's foot, but if it involves the nail, the products we carry require weeks and weeks of diligent therapy and it's better that you save time and get the correct diagnosis and a shorter treatment course. I have seen evidence of physicians who are so specialized that they know nothing out of their field of expertise. The more interaction with the patient and prescriber, the more knowledge to learn from. From a pharmcist's perspective, ten years after graduation, I went for PharmD, and the med students we studied and worked with were eager for my input, as well as older docs at the job site.

11:43 PM

 
Anonymous Anonymous said...

As a pharmacist, I don't particularly want to prescribe medications for anyone, even for myself--I'm apt to have the worst thing imaginable with a few extra symptoms, but I do love a good collaboration with the doc. When I have a legitimate medical concern, I don't like being fobbed off to the receptionist though, when they are allowed to pretend over the phone that they're the physician's right arm. If I'd been in the situation with the flu prophy, I'd have called the doc, if I saw need to question the script. Perhaps, that day the pharmacist had one too many secretaries call in refills for Vicodin and was thinking that the physician was not really acting in the patients' best interest. Just a thought. When I pull retail shifts, I do see and hear a lot of things, that my training has prepared me to offer a suggestion e.g. sorry we don't carry any antibiotics not obtainable without a prescription...please, see the doctor right away--you don't want to lose your sight, or yes, it's likely that's athlete's foot, but if it involves the nail, the products we carry require weeks and weeks of diligent therapy and it's better that you save time and get the correct diagnosis and a shorter treatment course. I have seen evidence of physicians who are so specialized that they know nothing out of their field of expertise. The more interaction with the patient and prescriber, the more knowledge to learn from. From a pharmcist's perspective, ten years after graduation, I went for PharmD, and the med students we studied and worked with were eager for my input, as well as older docs at the job site.

11:45 PM

 
Anonymous Iowaboy said...

Well put. You've put into words the split that has torn the profession of pharmacy in two.

As a clinical PharmD, I respond to orders requesting the treatment of diagnosed conditions. "RLL Pneumonia, tx per PharmD." I'm then sent into action researching the patient's background, medical history, calling other clinics who may have seen the patient recently, as well as every pharmacy the patient reports to me that he's used to get an accurate drug history. (Which very often reveals a surprise or two that needs dealing with). Then I'm left to link the history with the diagnosis at hand, call the nursing station for information that would let me calculate the patient's kinetic situation. Finally I select and initiate appropriate treatment and record my findings and activities under the patient's consultant tab. A Pharmacy consult. 30 min to two hours per patient, depending upon findings. (When do I get to bill for this? When, oh when do I get to bill for this??)

Across town, a retail pharmacist looks up from his coffee and paper to tell someone they don't need to fill their influenza prophylaxis.

We're both Pharmacists. We both have licenses. We both acted within the scope of our practice.

I'm not knocking retail pharms, there are some incredibly sharp ones out there. Likewise, there are probably a few duds in the clinical realm. Isn't the same true for physicians?

12:47 PM

 

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