Pharmacists changing prescriptions - thoughts?

[RxUBC]

UBCRx

 

How do you know you are attending UBC med next fall? Did you defer from last year?

 

I got a kick out of your list of barriers. #5 floored me. Wouldn't that be true for janitors as well. No offence to janitors.

 

shaka

 

Yes I was lucky enough to be allowed a 1 year deferral to finish my degree and for other reasons.

 

I didn't mean number 5 (ability) to be a slander hahaha - I'm a pharmacist myself =)

 

I meant that the pharmacist training is inadequate to initiate a NEW prescription because we lack many diagnostic skills learned in medical school...

[leviathan]

Leviathan, FMX - both nurses and pharmacists are key components of healthcare... no need to continue this comparison of professions...

Yes, they are both very important components...did I say they weren't? I just did not like FMX's condescending and uninformed view of nursing.

 

That said, I don't think pharmacists have a place in prescribing medications for patients except under certain circumstances. Because it is hard to delineate exactly when those circumstances render it safe and ethical, I don't think it should be permitted at all, or at least until someone can find a safe way to do it.

[FMX]

Just did a brief skim of the past few months as I haven't been on this forum too much and thought I'd just leave a quick comment before hitting bed on Halloween night (drank a bit too early..).

 

I did one full year of nursing school, including the anat/physio (UBC Biol153 equiv) and it was nothing compared to the full Phyl 301/Anat 390/391 combo. I still communicate with my nursing friends on a fairly regular basis, and I KNOW for a fact they learn nothing scientific past the first two years of school (in a 4 year program). For not having gone through the education yourself, you should not over glorify what nurses are really educated on as you will highly over-estimate their abilities. Ask any student nurse right now about the curriculum and they will tell you what a joke it really is.

 

All their pathology/therapeutics is really self-taught during their clinical rotation/experiences. They learn the patient diseases and look it up in their med/surg book, and they learn the drugs by looking through Davies drug guide for nurses.

 

I'm reading this over and I realize there might not be a point to this post.. but who cares good night!

[leviathan]

Just did a brief skim of the past few months as I haven't been on this forum too much and thought I'd just leave a quick comment before hitting bed on Halloween night (drank a bit too early..).

 

I did one full year of nursing school, including the anat/physio (UBC Biol153 equiv) and it was nothing compared to the full Phyl 301/Anat 390/391 combo. I still communicate with my nursing friends on a fairly regular basis, and I KNOW for a fact they learn nothing scientific past the first two years of school (in a 4 year program). For not having gone through the education yourself, you should not over glorify what nurses are really educated on as you will highly over-estimate their abilities. Ask any student nurse right now about the curriculum and they will tell you what a joke it really is.

 

All their pathology/therapeutics is really self-taught during their clinical rotation/experiences. They learn the patient diseases and look it up in their med/surg book, and they learn the drugs by looking through Davies drug guide for nurses.

 

I'm reading this over and I realize there might not be a point to this post.. but who cares good night!

Ha ha...I've actually done both Biol 153 AND Phyl 301 at UBC. I agree Phyl 301 is more in depth, but not by much. And I guarantee you anyone who takes Phyl 301 / Biol 153 and doesn't APPLY that knowledge to clinical medicine will not remember any of it, anyhow. For pharmacists, that means they only retain what they need to know for pharmacology (Understandably). For nurses, that means they apply what they know to their patients, which draws them closer to physicians for understanding of what a patient needs. If a nurse just administered whatever drug a physician ordered her to give (as you so put it), and that was a gross mistake, s/he could lose their license. E.g. if a physician ordered to give 10 mg of epinephrine to someone having an allergic reaction, she would probably not be a nurse for much longer. Or if she gave 0.3 1:1000 by IV, as another example.

 

I can just imagine a pharmacist trying to do the job of a nurse in the ICU. Your understanding of nursing based off doing first year is exactly why you may have such a MISunderstanding of what they are capable of.

 

I don't know what we're arguing about anyhow, because neither pharmacists nor nurses should be prescribing drugs.

[monkey799]

So RxUBC is just starting the long road of medicine, young and naive. There is a big reason why BCMA president is speaking out against pharmacist prescribing, and I suggest RxUBC do more investigation and talk to more doctors before making statements that don't make sense. But let's cut RxUBC some slack here as he/she is in the club.

 

Every year there are many experienced pharmacists, pharmacy graduates and students who got in early in the medical school program, and RxUBC will be surprised how LITTLE they know about medicine - even drugs.

 

Not to under-estimate the importance of drugs, but pharmacology is taught mostly as independent study with a few lectures in first 2 years of med school. Most med students can learn the basic stuff from reading books and drug cards. The real interesting part of clinical pharmacy is learned in the context of medicine.

 

Pharmacists and pharmacy students, like most students in med school, are inexperienced in interpreting lab values when starting out the clinical years. This is speaking from seeing my colleagues with pharmacy background. Things like sodium, potassium, calcium and whatever lab abnormalities requires years of medical training and experience to be able to manage property. To think that an undergraduate pharmacy degree is sufficient to prescribe SAFELY for abnormal lab values is totally naive, and gets laughed among medical students and residents. It's this kind of attitude - thinking you know more than you do - that gets patients harmed.

 

For the record, of the 15 or so former pharmacists in my med class, most are AGAINST pharmacist prescribing from social chit chats. They are not vocal about it when hanging around the non-MD pharmacists.

[RxUBC]

haha well thanks for "warm" welcome to the club lol...

 

I'm not a proponent of pharmacists prescribing per se... if you read my posts carefully, I feel that pharmacists are capable of renewing or adapting prescriptions - prescribing is only ok for basic medical conditions such VVC or acne etc.. nothing hardcore obviously...

 

I will certainly let you guys know what my stance is when I graduate but I feel that I was at one time a pharmacist (for 4 months) and the least I could do is give back to pharmacy by being open minded about the ability of a pharmacist when I am practicing as a MD

[meme me]

It's interesting to see this debate so focused on the science. What about the political and professional apendages of this debate? Would anyone, for instance, be willing to admit that any threat to the powers of the physician is consistently met with their rancorous objection? Surely there are situations where the pharmacist renewing prescriptions is a bad idea, but why not explore the specifics of this arrangement in more detail, with more collaboration so that the situations where this is obviously beneficial to everyone involved are realized, instead of squashing the idea with this collective, inflated ego physicians seem to grasp to so strongly?

 

To those opposed to this idea because it "fails to acknowledge the root of the problem"... I'm not sure what to say... would it be your suggestion then, to do nothing about the physician shortage and wait-time epidemic unless it's directly addressed? That's ridiculous. It's unrealistic to think that we can solve the enormity of this problem by simply training more physicians and letting more foreign trained MDs into the country to practise. This problem, the physician shortage, is going to require a multi-pronged approach and willingness from everyone involved to collaborate with a more integrated health-care team. The prescription issue is part of this.

[meme me]

But let's cut RxUBC some slack here as he/she is in the club.

I really hope this comment is a joke.

[Satsuma]

To those opposed to this idea because it "fails to acknowledge the root of the problem"... I'm not sure what to say... would it be your suggestion then, to do nothing about the physician shortage and wait-time epidemic unless it's directly addressed? That's ridiculous.

 

Wanting to address the root of the problem is not equal to suggesting we do nothing about our physician shortage. That leap in logic is what`s ridiculous.

 

Surely there are situations where the pharmacist renewing prescriptions is a bad idea, but why not explore the specifics of this arrangement in more detail, with more collaboration so that the situations where this is obviously beneficial to everyone involved are realized, instead of squashing the idea with this collective, inflated ego physicians seem to grasp to so strongly?

 

You managed to preach the merits of working collaboratively while bashing physicians all in the same sentence...good work.

[xylem29]

I really hope this comment is a joke.

 

It's not a joke, being in med school means you're part of the medicine club. Are you in med school, if you are you should know what I'm talking about.

 

I'm not, but I was accepted to a US school (declined) and let me tell ya...I wasn't even accepted into a Canadian school and I still experienced some of the club aspects, lol...you are definitely set once you're in (and I'm not talking about money).

[meme me]

Wanting to address the root of the problem is not equal to suggesting we do nothing about our physician shortage. That leap in logic is what`s ridiculous. .

It's not ridiculous, and there's no leap. Individuals have expressed their dismay at tackling the problem of physician shortage unless it addresses the root of the problem... obviously the root must be addressed, but in the meantime, we've got to look at taking steps toward easing the workload today. As I said in previous post, solving the physician shortage is going to take a multi-pronged approach; training more physicians and allowing more to practise is one part of that approach.

 

 

 

You managed to preach the merits of working collaboratively while bashing physicians all in the same sentence...good work.

Great contribution... the comment is obviously directed at those physicians resisting collaboration in an effort to protect the hierarchy of the health care system. My sentence then, accompished its goal.

[leviathan]

As I said in previous post, solving the physician shortage is going to take a multi-pronged approach; training more physicians and allowing more to practise is one part of that approach.

Sorry, but I don't think the number of prescription visits to the clinic constitutes any burden on the system. It is annoying for the patients, but it is not making wait times any longer.

[meme me]

Sorry, but I don't think the number of prescription visits to the clinic constitutes any burden on the system. It is annoying for the patients, but it is not making wait times any longer.

No need for an apology. This is about improving efficieny and access in a bloated health care system and this reform would do both. The issue at hand does not address wait times; it is addressing the chronic shortage of family physicians available to Canadians. Trimming some fat off unnecessary family physician duties helps to enable them to take on more patients.

[leviathan]

No need for an apology. This is about improving efficieny and access in a bloated health care system and this reform would do both. The issue at hand does not address wait times; it is addressing the chronic shortage of family physicians available to Canadians. Trimming some fat off unnecessary family physician duties helps to enable them to take on more patients.

As I said the number of people that come to physicians for prescription refills is hardly a significant amount. In my opinion, I don't think that would allow them to see any real difference in number of patients. Physicians are also happy to see prescription refills as it is a quick and easy billing for them.

[meme me]

As I said the number of people that come to physicians for prescription refills is hardly a significant amount. In my opinion, I don't think that would allow them to see any real difference in number of patients.

What are you basing this on? Do you have experience working with or as a family physician? I would be curious to see the percentage of a family doctor's time is taken up by these sorts of appointments.

 

And I'm not here to argue how little or how large this will improve conditions. The point is IT'S PART OF A MULTI-PRONGED APPROACH AT ADRESSING A CHRONIC PROBLEM and we need to start moving and doing things to improve the pathetic inefficiency of our system.

 

And regarding your comment of billing... thanks for addressing this. No wonder there is such a physician barrier to these sorts of reforms... doctors will be losing out on some easy cash.

[Satsuma]

Great contribution... the comment is obviously directed at those physicians resisting collaboration in an effort to protect the hierarchy of the health care system. My sentence then, accompished its goal.

 

It wasn`t actually clear to me that your sentence had a goal other than to bash physicians. Thanks for clarifying that it was only meant to bash some physicians.

 

Either way, attacking the very people you want to have work "with" you is counterproductive.

 

I tend to agree with Leviathan that prescription refills likely don't burden the family doc that much. They do not at all take a long time and it is an opportunity to touch base with the patient. If I had to estimate, I would say I saw maybe 1 or 2 refills a day on average in family med. That is probably being generous since I did not see refills every day even.

 

Currently, in Ontario you can ask your pharmacist to get a verbal phone order for renewal of meds (or fax or however they want to do it). I have done it a few times, and I see that as perfectly fine, since there was still communication with my family doc for their records and they had the option to decline if they felt they needed to see me.

 

As for wait times, these data are rather unreliable, although politicians like to throw them around alot, so they must be taken with a grain of salt. The way in which wait times are measured is inconsistent, doesn't take into account the fact that many physicians place pts on waitlists before they are even sure the pt needs to be on the list, doesn't take into account the pt that cancelled his/her appointment/or didn't show up, doesn't take into account the acuity of the situation or the outcome.

 

Generally, if you NEED to be seen, you WILL be seen. If you are waiting for months and months to get an appointment...it's likely that you will be just fine during that wait, or you would have been seen earlier.

 

There is no perfect health care system. And there are certainly areas for improvement in the Canadian healthcare system. But overall we aren't doing too badly. A group of Harvard researchers published data in the American Journal of Public Health in 2006 that showed Canadians had better outcomes (including better access) than Americans in terms of health and we spend half as much on healthcare as they do.

 

You might not have access to healthcare "at your convenience" with our system. But you will have access and you will get what you need.

There are certainly a number of people who think healthcare should be as convenient as fast food but that just isn't realistic.

[meme me]

A group of Harvard researchers published data in the American Journal of Public Health in 2006 that showed Canadians had better outcomes (including better access) than Americans in terms of health and we spend half as much on healthcare as they do.

Touting the merits of our health care system against the United States' is pretty laughable.

 

Here's a report on a more recent/appropriate comparison.

 

http://www.fcpp.org/main/publication_detail.php?PubID=2020

 

If those results don't frighten you, they should.

[leviathan]

What are you basing this on? Do you have experience working with or as a family physician? I would be curious to see the percentage of a family doctor's time is taken up by these sorts of appointments.

I have a few friends who are family physicians and have a good idea of the typical number of refills they get.

 

And I'm not here to argue how little or how large this will improve conditions. The point is IT'S PART OF A MULTI-PRONGED APPROACH AT ADRESSING A CHRONIC PROBLEM and we need to start moving and doing things to improve the pathetic inefficiency of our system.

No, it's part of a multi-pronged approach at cutting costs in any way possible at the risk of patient safety.

 

And regarding your comment of billing... thanks for addressing this. No wonder there is such a physician barrier to these sorts of reforms... doctors will be losing out on some easy cash.

I'm sure that's part of it. Another more important part is the dangers of giving such a huge power to pharmacists to not only refill prescriptions but CHANGE doses and other related functions. This is an excellent idea for a very small window of patients, but from what I understand they are getting free reign to prescribe to any patient they wish.

[coastalslacker]

What are you basing this on? Do you have experience working with or as a family physician? I would be curious to see the percentage of a family doctor's time is taken up by these sorts of appointments.

 

And I'm not here to argue how little or how large this will improve conditions. The point is IT'S PART OF A MULTI-PRONGED APPROACH AT ADRESSING A CHRONIC PROBLEM and we need to start moving and doing things to improve the pathetic inefficiency of our system.

 

And regarding your comment of billing... thanks for addressing this. No wonder there is such a physician barrier to these sorts of reforms... doctors will be losing out on some easy cash.

 

Just to reiterate what others have said, these visits take up little to none of a family physician's time and pharmacists prescribing for the reasons you mentioned will have little to no impact on improving our health care system. This is based on my experience working with family physicians while in medical school and talking to friends who are either in family medicine residency now, or, already practicing as family physicians.

 

Our system certainly is inefficient. I'm not sure what capacity you work in the system in, however, it seems to me that you don't have a very good grasp of this issue. Cheers.

[A-Stark]

Touting the merits of our health care system against the United States' is pretty laughable.

 

Here's a report on a more recent/appropriate comparison.

 

http://www.fcpp.org/main/publication_detail.php?PubID=2020

 

If those results don't frighten you, they should.

 

I'm generally not frightened by arbitrary rankings put out by think tanks.

[ploughboy]

Not sure about all prescription refills being quick in-and-outs. In my third and fourth year family electives, there have been a couple of "refill" appointments where the patient made an offhand comment that ultimately resulted in a change to their medical management. Of course I tend to FIFE the bejeezus out of my patients...

 

I'd also argue that it's useful to see select patients every few months not only to renew their meds, but to praise them for the good things they're doing, nag them about their bad habits (ie smoking) and just make sure that they're generally holding things together.

 

My two cents.

[ploughboy]

On the other hand, pharmacists are incredibly useful within their domain of knowledge. I had a patient this week who is out at the edge of the bell curve -- he has a long list of medical conditions, a long list of medications and a really long list of sensitivities to medications.

 

He had failed two previous antibiotics, so we were considering a third. My preceptor and I sort of looked at each other and shrugged, because we had no idea what the potential interactions were. The team's pharmacist, however, was all over it and gave us some good advice.

[xylem29]

On the other hand, pharmacists are incredibly useful within their domain of knowledge. I had a patient this week who is out at the edge of the bell curve -- he has a long list of medical conditions, a long list of medications and a really long list of sensitivities to medications.

 

He had failed two previous antibiotics, so we were considering a third. My preceptor and I sort of looked at each other and shrugged, because we had no idea what the potential interactions were. The team's pharmacist, however, was all over it and gave us some good advice.

 

Bang on...

 

As for "prescribing" for minor ailments, I'd like to mention an anectodal story that happened to me. I was all high and buzzy after taking a pharmacokinetics class a few years ago and had learned about just how much pharmacists knew about medications, etc. Anyway, one day - I developed these ithcy red patches on my chest and figured I'd go to the pharmacy to see a pharmacist rather than my FP, b/c it wasn't too irratating and I didn't want the hassle of seeing the FP (making appointment, waiting, etc), I wanted a solution fast. Anyway, I go and and explain to the pharmacist that I had been going to a public gym and thought that it might have been something from that, they took a look and said it was an infection and I should take polysporin. Didn't even tell me that I should probably go and see my doc - she was so certain of herself.

 

Anyway, I take the polysporin and it didn't do anything. A few hours later my neck is swollen and the patches are all over my body. Went to the emerg and it turns out I had hives, that it was an allergic reaction.

[Satsuma]

Touting the merits of our health care system against the United States' is pretty laughable.

 

Here's a report on a more recent/appropriate comparison.

 

http://www.fcpp.org/main/publication_detail.php?PubID=2020

 

If those results don't frighten you, they should.

 

 

I don`t think it is that laughable. It is a natural comparison as they are our closest neighbour.

 

As for comparing ourselves with European countries, I think that is a great thing because there is a world outside of North America.

 

But as I said, our healthcare system is not perfect but you get what you need. And the data from the publication you reference support this.

 

In this first edition of the Euro-Canada Health Consumer Index, Canada places 23rd out of 30. With respect to clinical outcomes, Canada compares well with the best performing healthcare systems.

 

Yeah, we lose point for wait times, accessibility and such. But that is really no surprise. We know these are issues. My point is that these are issues that are not affecting outcome. So nope...not frightened.

[leviathan]

Bang on...

 

As for "prescribing" for minor ailments, I'd like to mention an anectodal story that happened to me. I was all high and buzzy after taking a pharmacokinetics class a few years ago and had learned about just how much pharmacists knew about medications, etc. Anyway, one day - I developed these ithcy red patches on my chest and figured I'd go to the pharmacy to see a pharmacist rather than my FP, b/c it wasn't too irratating and I didn't want the hassle of seeing the FP (making appointment, waiting, etc), I wanted a solution fast. Anyway, I go and and explain to the pharmacist that I had been going to a public gym and thought that it might have been something from that, they took a look and said it was an infection and I should take polysporin. Didn't even tell me that I should probably go and see my doc - she was so certain of herself.

That's exactly the thing...if you told a pharmacist that XYZ is an infection, I'm sure they could provide some tips on what kind of medication would treat it. (But by the way...topical polysporin for what could be a nasty case of cellulitis?)

 

However, if you expect a pharmacist to be able to IDENTIFY an infection or a medical problem, they are completely out in left field. Pharmacists don't have clinical/medical training and would have no idea what a skin infection looks like vs. an allergic reaction, or how to do a proper physical exam + assessment.

 

Great example, xylem!