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.