kwizard said:
For better or for worse pharmacists will have to eventually obtain prescribing privileges, especially if clinical pharmacy is going to survive (or fully thrive). Without the "power" to prescribe then it is pretty hard to bill for service. You can do all of the med management and counseling you want, but since a pharmacist isn't going to peform an invasive procedure; autonomy needs to be gained for treated pts. Otherwise you just counsel a pt and make your reccomendations to the clinician w/ prescribing privileges and let them bill for your ideas.
Various templates are out there in the various collaborative practice agreements in many states and the various directives in federal sector granting "clinical pharmacists" the right to define a scope of practice w/ prescribing privileges. I remember providing links to articles/directives when this subject came up earlier? Even on a more basic level, most pharmacist in hospital settings have protocols passed by the hospital P&T committee meeting allowing pharmacist (entire dept or a selected few) to renal adjust antibiotic dosing, prescribe anticoag meds (inpt or outpt), order TPNs or adjust and/or order other meds that can be followed via a drug level (i.e. therapeutic drug monitoring of antisz meds, digoxin, etc.). When dealing w/ antbx dosing the same pharmacist adjusting the dose based on renal function is often the same pharmacist dispensing med.
Checks and balances scenario...I know the big fear is that if all pharmacists have prescribing privileges than who is checking the meds? Well in most cases what we may see in the US is "clinical pharmacists" as the ones actually using these prescribing privileges and a separate group of pharmacists still responsible for checking the medication to ensure it is appropriately written, no ADRs, drug interactions, etc. I only use the term "clinical" pharmacist to describe the individual who has gained the necessary requirements to obtain prescribing privliges as so defined by their practice setting and/or state/federal regulations. Think of it like Nurse Practitioners (NP). A NP is basically a RN w/ additional training (i.e. a BSN and MSN w/ several more yrs of clinical training than a RN) and we are all registered pharamcists (some w/ more clinical training than others). However if a NP wanted to pick up extra hrs, they could always still work as a RN if they wanted to. I know some NPs who moonlight periodically as RNs on the floor and actually make more per hr as a RN then they do per hour as a NP given the shortage for RNs on the unit. Maybe not the best analogy, but I'm just trying to illustrate that you can have more than one tier of professionals within one profession.
So therefore the likelihood of someone prescribing and dispensing all in the same course of action would be rare. However in some cases when your working with limited staff or you need the drug in a quick manner you sometimes do see the same pharmcist who prescribes the med also processing the order and dispensing (I typically only do this in the case of coumadin dosing on wknds or antibiotic dosing w/ stat doses). Otherwise it would probably be most appropriate ethically for another pharmacist to check the order.
Doctors prescribing and dispensing...Well I guess it depends on how many samples they give out. Nonetheless I don't think this will be a worry as inventory for keeping so many meds in the office would be too much of a hassle for the many physicians to even want to bother with.
I agree with much of what Kwizard has said. However, I do feel prescribing will be within a collaborative practice agreement model or for medications which might be moved to a "by pharmacist access only" level - between OTCs & rx (excluding the pseudoephedrine debacle currently). I don't feel retail pharmacists have access & time for complete physical & laboratory assessments, so the medications which they might have available to "prescribe", for lack of a better word, would be those which have shown themselves to be "safe", but which might be misued - fluconazole 150mg po as one example.
Inpatient drug protocols and adjustments are so commonplace by pharmacists that I believe its a non-issue. They have access to labwork which makes dosing so much easier.
There are a couple of misconceptions, I feel, regarding drug education of physicians. Long, long time ago, when I was a student, I took microbiology, biochemistry & physiology with medical & dental students during my first two years. Drugs were introduced during that time & mechanisms discussed (ie - gm+ cocci susceptible to pcn due cleavage of beta-lactam ring in cell wall, how resistance develops, etc). Obviously, my education went on in my direction, but their exposure to medications also went on in theirs. My daughter as a second year medical student now has had similar exposure. In her first year, she learned about antibiotics during micro, during second year she is learning anticonvulsants, adrenergic agonists, sedative-hypnotics, etc in neuro. Now, she is learning basic pharmacology - no kinetics or dosing yet. When she gets into more diagnosis, rather than just altered & normal physiology, she'll learn why you choose one over the other. The semester of pharmacolgy goes over the classes & reviews the differences within classes (ie lidocaine, flecainide, encainide, etc..), kinetics, toxicology, etc..Yes..much less than the detail we learned didactically, but over the 4 years of medical school, far more depth with regard to using drugs to manage disease states. However, the real depth comes with their residency.
As far as prescribing authority, a physician has full prescribing authority after they receive their MD/DO & have passed two of their licensing exams (STEP I & II for MD's). They do not need to finish their residency for this to happen (after all - some surgeons can take 7 years to finish residency alone!). But...my experience with new physicians is just because they can prescribe doesn't mean they do prescribe. By the time they have started on their residency, they usually have the sense there is so much more they still don't know than they do know. A first year resident doesn't write many orders independent of consultation with their senior resident or attending, so their education on how drugs are utilized within their chosen specialty is continued on for more years.
One final thought which always bothers me is the sense of "turf". Ask yourself a question - do you want prescribing authority because you feel you "deserve" it or is it better for the patient? Good patient care should always be the priority, IMO. If we can improve access for safe & effective medications in which a delay of diagnosis will not adversly affect the pts outcome, then by all means, we should find a way to do it. But...if our lack of diagnostic capability results & giving an incorrect medication, the I'd question if that were really in the patients best interest. I apologize for the long post....I'm way too windy!