Have you ever read the little piece of paper you sign at the pharmacy when you're picking up a prescription? Most people think they are confirming receipt of the medication. If you have read it, you'll know you've just confirmed that you didn't want to speak to the pharmacist for counseling.
Frankly, they're too busy counting pills.
I wonder why my wife, who is obsessive enough to count the pills from every prescription she receives, only ever finds that she has been short-changed. She has never once been the beneficiary of an error in her favor.
The FDA is holding hearings about allowing pharmacists to dispense medications currently available only by a physician's prescription. Pharmacists already dispense good advice about medications, direct people about over-the-counter drugs, and control a new class of controlled drugs that do not require a prescription. Specifically Plan B, the morning-after contraceptive, and many cold medicines, are kept behind the counter, to be sold only on a pharmacist's recommendation. This is the way many medications are sold in Europe, and they're healthier than Americans, right? It improves access for patients, so it has to be a good thing.
Presumably the college drop-out who manages and evaluates the retail pharmacist's performance, also gets to supervise the professional acceptability of behind-the-counter sales. Of course, the corporate chain retail pharmacies will be responsible enough to temper the incentives to sell as much product as possible, with some sense of quality control. The right of a pharmacist to refuse to provide any medication will be protected by a recognition that these pharmacists are independent and responsible professionals who know exactly what they're doing. Since counseling takes time, I am certain that retail chains and supermarkets will hire additional pharmacists to ensure the best possible advice for their customers.
I personally have no objection to psychologists, physical therapists and other paraprofessionals prescribing and being responsible for medications. I am quite certain they are capable of ordering lab work to detect liver and kidney abnormalities and examine patients to make sure the medication is working effectively.
OK, I will stop the sarcasm for a second right here...
In fact, allied health professionals are NOT specifically trained to monitor patients for side-effects and effectiveness. All they can do is dispense. I will not treat the side effects produced by another professional's decisions, except in an emergency. It is bad medicine and both the patient and the physician deserve the continuity of information. This is how we learn, even in the absence of a mistake.
Let's not forget the patients. My clinics dispense free medication at our $30 sliding scale visits. I cannot tell how often patients show up only wanting the medication and refusing to pay $30 to see the doctor, despite the fact that they are not under control and it has been 3 or 6 months or more since they were last seen.
Finally, let's make sure the trial lawyers are safe. After all, they have easy pickings with primary care physicians and drug companies when things go wrong. By shifting the responsibility to patients and pharmacists (whose liability coverage is not as rich as physicians), trial lawyers could find themselves out of significant contingency fees.
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"In fact, allied health professionals are NOT specifically trained to monitor patients for side-effects and effectiveness. All they can do is dispense. I will not treat the side effects produced by another professional's decisions, except in an emergency. It is bad medicine and both the patient and the physician deserve the continuity of information. This is how we learn, even in the absence of a mistake."
I find it slightly hilarious that you feel qualified to comment on what is and isn't learned during something like pharmacy school. I'd never be so arrogant as to comment about what is and isn't learned in nursing school or med school. I'm not a nurse or a doctor, I have no idea. I have a general idea, but not enough to spout my mouth off as though it's some sort of gospel truth.
In fact, pharmacists DO look into lab values (blood counts) today for drugs like Clozaril. So your insinuation that RPhs are not trained and unqualified to do such things is plain wrong.
It IS true, however, that most pharmacists don't *want* to do this. They wanted to be dispensers and are perfectly happy in that role. But they *were* trained to do this once upon a time, and most of them know the things to look for as a result of a particular drug therapy. While most won't remember what proper lab values are because they haven't had to use this knowledge in a while, they did know them once upon a time because they *had* to. Frankly, this isn't important, either, because right now, pharmacists aren't responsible for drug monitoring, as you've pointed out. You bet your ass there'd be an exam to ensure competency before any such thing were enacted. (At least I hope there would be. Scary thought if there isn't.)
And the pharmacist being responsible for the entire spectrum of drug therapy (including patient monitoring) happens quite often in controlled environments like nursing homes. And these folks will most likely run circles around you when it comes to their specialty (old people). I'll take an average CGP over an average MD any day of the week for the geriatric population. And you would, too.
"Frankly, they're too busy counting pills."
Pharmacists rarely count pills unless they're CIIs. But please, by all means, continue to educate us on how the pharmacy does and does not operate since you're obviously qualified to do so as an outsider looking over that counter.
Thank you for your comment, but I used to contribute to the training of RPH's during my time teaching at a residency. I am aware of how good the best can be and have since become aware of skewed the bell curve can be. There are some terrible pharmacists out there.
I guess your point of the average MD and the average CGP is right on. Who's talking about averages?
And physical examination still has a role, despite the seemingly universal reliance on lab values as the primary tool in managing the "entire spectrum of drug therapy."
I always welcome the contributions of a well-trained and competent RPh in a collegial environment. However most of these work in hospitals, not in retail chains.
I mourn the death of the mom and pop pharmacy and the absence of pharmacists who can read.
Haha. I don't disagree with you about the state of pharmacist knowledge. I've actually posted a couple of blog entries lately about the performance (and apparent lack of knowledge) on the part of some pharmacists I've worked with. Some cringe-worthy stuff. Generally I think the problem is with motivation. The barriers to entry at some pharmacy schools are pretty low, especially if they're integrated programs that take students right out of high school. More traditional programs that require an undergrad degree, or at least a plethora of undergrad credits are more difficult to get into. The requirements for these programs aren't much different from applying to med school, in fact.
Generally speaking, bad pharmacists are the product of bad mentors. At least in my experience. I think the practice of pharmacy has lost something when it moved from what was largely an apprenticeship to more class-based learning. (It gained a great many things, but I think one of things it lost was deep-down-in-your-bones competence. The demise of the independent pharmacy has also contributed.)
I suspect this could be avoided by having a residency requirement where you work closely with the same people for a significant span of time.
"Who's talking about averages?"
Well I assumed you were...
And physical examination still has a role, despite the seemingly universal reliance on lab values as the primary tool in managing the "entire spectrum of drug therapy."
I don't disagree.
I always welcome the contributions of a well-trained and competent RPh in a collegial environment. However most of these work in hospitals, not in retail chains.
It always has been that way. Dispensing is more "valuable" (in terms of financial incentives), and most of the clinical knowledge one has disappears over time when one is more concerned with machine-gunning prescriptions out as quickly and accurately as possible. If retail types needed to use it, they would retain it.
My main complaint was your characterization (intentional or otherwise) of all pharmacists as incompetents. This is obviously not true. (Just as there are quite a few people I would consider morons who have the letters "MD" after their names.) The pharmacy profession has quite a few problems it needs to fix. These problems are immediately apparent to anyone who's worked in the field. Medicine is the same way -- I'll stick to pointing out flaws in my own field in the meantime, it might not hurt if you did the same. Or at least did it in a different way. Putting folks on the defensive is never a good way to effect change.
I also get the impression that you view most pharmacists as med school rejects, which is also a gross mis-characterization. Nonetheless it is a perception that persists still.
Ahh, the perils of sarcasm...
I have met enough pharmacists I respect to apologize for certain perceptions:
1) I do not intend to characterize all pharmacists as incompetents. Push me and I'll tell you what I think of most retail pharmacists and it won't be pretty.
2) I don't think pharmacists are med-school rejects. I think the good ones were too smart to get sucked in!
However, a policy decision of providing access to medication without access to good medical advice (which, in this case is coming from the retail pharmacist) needs to be seriously questioned, especially in the retail pharmacy context where non-professionals manage and influence the weakest pharmacists.
Just to get things straight . . . . how many course in pharmacology has the average physician taken in his/ her life. Is it one or two? Seems like all the complaining about the stupidity re: drugs of pharmacists is the pot calling the kettle black.
Prescription medication is, itself, a crime against individual freedom. A crime, however, that doctors find extremely lucrative. Not surprising, they want to keep the proceeds of this crime to themselves.
Let's run this experiment and see if bad things result from pharmacists prescribing!! The chicken-little reaction we get from doctors over the last 40 year at any incursion into their monopoly is getting old (PA, nurses, midwives) Yet, the expansion of the rights to perform medical procedures has NEVER been shown to be detrimental to patients.
Maybe the physicians are just blowing smoke
Here in Illinois the new pharmacy practice act permits pharmacists to prescribe and monitor treatment under a doctor's directive. This allows pharmacists to practice medicine if the pharmacy hires a doctor to provide the necessary directive. Osco, Walgreen, Walmart, etc will be able to establish pharmacist-run clinics for common diseases now run by MDs, PAs, NPs, etc. Osco is considering doing anticoagulant clinics run by pharmacists. Some universities and hospitals already do so. This may solve the problem of an increasing dearth of physicians entering primary care. We will just replace them with NPs, PAs, and pharmacists.
I am going to catch a lot of flak for this but pharmacists are not trained in the art of medicine. They have great expertise in the use of medication and are actually quite good with the 1/million patient who is convinced that their medication regime is beneficial and is capable/motivated to adhere to it. Outside of that situation, however, they are completely flummoxed.
I bow to their knowelege of medications, I question their knowlege of how and when they should be used and I am certain that they do not have the training to establish a long term therapeutic relationship with the vast majority of regular folks.
The pharmacist I work with in the NH is a great guy, with wonderful book knowlege of the meds I use. He is totally incapable of talking to the family of a ninety six year old demented patient who is conviced she must have her Fosamax and Coumadin. Most surgery can be learned by rote, indeed that is how surgeons learn to do procedures. It is knowing when to operate and to be prepared for what comes after that separates me from a surgeon.
You think there are problems with overuse of these medications now, like abx or anti depressants, just wait 'till you lower the barriers to obtaining them,
I have no problem with folks getting any meds without a prescription. Everyone is entitled to go to hell in the way that seems best to them. If I lose exclusive prescribing authority in my state, however, primary care access will get worse, not better. We have a contingency document reviewed by my carrier that every person in my practice will have to sign that fires them if they get any prescription meds from anyone except me if prescribing authority devolves in our state. There is no way I would want to take on a sniff of the liability of unsupervised prescribing. If pharmacists and psychologists were smart, they would not either. If they think they have liability exposure now, just wait..........
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rjs & pharmacists here, while there's little doubt you're medication experts, medication is but only part of a medical treatment regime. Pharmaceuticals're a tool and a tool is pretty much useless and even dangerous if the user hasn't a clue of when, where and how to use them. The reason being, pharmacists're not trained in diff. diagnosis & pathologies the way doctors're.
"I also get the impression that you view most pharmacists as med school rejects, which is also a gross mis-characterization."
Not according to higher education statistics for the health sciences.
In Australia, the Tertiary Education Councils had compiled a list of health program preferences of people entering universities and still found that over 90% of those who had Pharmacy as a preference, always had Medicine as the 1st. Compared to Medicine, very few chose Pharmacy as Number 1 preference.
BONEHEAD
People in any profession should do that which they were trained to do. In fact, as a physical therapist, I WAS trained to monitor the adverse effects of drugs I prescribed for my patients in the Army. I did NOT dispense these medications. Granted the list of what I was permitted to prescribe was short, as was - without doubt your education on medical jurisprudence.
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