Questions PharmD --> Medicine

[Dr JPH]

Originally posted by PACtoDOC
If you want to practice medicine, you have to go to medical school. You can only practice medicine as a DO/ MD, and that's that. Before I started med school I was a practicing PA who thought that I was by many rights as fit to practice medicine as my physician colleagues. I was wrong. So do you know what I did, I went to medical school.

Pharmacists have a skill that can and only allows for them to dispense medications after they have been ordered by a physician, PA, NP, OD, DPM. The common thread that all these providers have is literally years of normal anatomy, abnormal physiology and pathophysiology, embryology, psychology, pharmacology, biochemistry, histology.

I say pass out the USMLE step one at the grocery store and any person who can pass it under proctured settings should be able to practice medicine. Without the cumulative total of these classes above, it would be impossible to pass this exam, and thus it would be a mute point.

When a pharmacist is required to spend the same amount of time in the basic clinical sciences of medicine, then they will no longer be pharmacists. What pharmacist would still want to be a pharmacist once they had taken the first two years of medical school only to continue on to become a pharmacist?

Pharmacists and Psychologists have their place, but neither should be making individual decisions on the what is best for any patient in terms of medications.

Are you kidding me?

OK...some of what you said makes sense.

But to say that Pharmacists are only trained in pill counting? Give me a break. You have obviously spent little or no time with a pharmacist in an academic setting.

Maybe you are bitter because a pharmacist showed you up at some point in your life.

Hell...I saw early on that pharmacy was not for me. NOT because of lack of interest. NOT because of a worry of lack of respect. NOT because I felt that I would be beneath anyone.

I wanted to become a doctor because THAT was the role I wanted to fill in the medical field.

Hell...I know that when I am practicing in the hospital some day I sure as **** want a pharmacist somewhere around whom I can consult about medication problems. Who the hell but a pharmacist can really keep all those parenteral penicillins and cephalosporins straight, anyway?

Two final points that seem to be a recurring theme:

1. No, pharmacists are not diagnosticians and should not be looked at as such. This is what physicians are for. However, do pharmacists know more about the medications physicians sometimes (often times, for some docs) write blindly to patients? You bet your ass they do.

2. As far as the "doctor" issue. Doctor is a title of respect. It is not a medical role. MD/DO are PHYSICIANS with the PROFESSIONAL title "doctor". Do I think that PharmDs deserve the professional title and respect? Sure. Does it make it more difficult and confusing in a professional setting? Yes it does. I have seen it and seen how and why problems can arise.

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[tlh908]

Originally posted by PACtoDOC

Pharmacists have a skill that can and only allows for them to dispense medications after they have been ordered by a physician, PA, NP, OD, DPM. The common thread that all these providers have is literally years of normal anatomy, abnormal physiology and pathophysiology, embryology, psychology, pharmacology, biochemistry, histology.

Hasn't this been discussed already? Pharmacists are trained in anatomy (yes, we even have gross anatomy), pathophysiology, pharmacology (more in depth than med students), biochem, and do touch histology and embryology. No we can't diagnois, but to say we can only dispense shows ignorance of the profession.

 

[rose13]

Originally posted by LSUMED2006
It seems MANY people want to be doctors, CRNAs, NPs, ODs, etc., but they DON'T want to go through what every physician has to do to earn his degree. I must agree with tenmesa. For those who want to prescribe, manage patient care, etc. indepentdently, then why not become a physician, rather than want equal responsibilities with much less training?

Jason

I was browsing and I found your comment interesting. I am planning to attend OD school. For a long time, I compared the pros and cons of MD/DO vs. OD. After a lot of self analysis, the OD is the better route for me for a variety of reasons. I am only interested in the eye and optics. After speaking to OMD's and ODO's, I realized that there is no guarantee that I would match into ophthalmology residency. Also, I am not interested in eye surgery (or any other type of surgery), another aspect of the ophthalmology training. I did the volunteer work and found out what it is like to have someone die on you; this is not what I want to do for a living. I am not interested in delivering babies, working in the emergency room, etc. Optometry school is 4 years and 1 year of residency (I plan to specialize). So I am going there with a guarantee to do what I am comfortable with. I do not want "equal responsibilities with much less training." That is why I am chosing to go straight into my speciality, rather than going the generalist route then specializing; OD's are specialists and are not generalists and do not purport to be. I am not interested in being a generalist; I want to do what I will be trained to do--treat ocular problems that DO NOT require surgery. But then again, you have insurance company administrators making the final decisions for physicians and other non-physician health care providers, so why bother with med school anyway?

 

[Dr JPH]

Originally posted by rose13
But then again, you have insurance company administrators making the final decisions for physicians and other non-physician health care providers, so why bother with med school anyway?

NOW you tell me.

 

[PACtoDOC]

JP Haz,

I hate to be the bearer of bad news, but as a prescribing provider (even as a PA), I have to be able to distinguish between those cephalosporins and parenteral PCN's every day. Maybe that is the problem, that pharmacists have this notion that they truly know the drugs better than physicians. I can guarantee that a pharmacist does not know insulins better than an endocrinologist, or beta blockers better than a cardiologist. And I doubt that most pharmacists know as much about primary care drugs as PCP's. Heck, I have pharmacists calling me and wasting my time to tell me that John Doe is allergic to the Keflex because he had a slight reaction to Ceclor when he was a kid. The providers know the intricate nature of their patient's situations, and pharmacists often times see only black and white. I honestly will go out on a limb here and say that I love the idea of the PharmD, because hopefully it will select against some of these scary retail RPH's who I sometimes feel aren't as smart as their store cashiers. I think you will see the other side of the picture when you start having the responsibility of writing scripts JP. But I understand that you probably saw a bunch of dumb docs making script errors, and based on the fact that you got into med school, you must have been one of the smart pharmacists. But they aren't all like you I can assure you.

 

[Dr JPH]

PACtoDOC

I respectfully disagree with your earlier post (your more recent post says it a bit better), but nevertheless I will admit that you are in more of a position to comment on this particular topic...at least from the side of clinical medicine.


Best of luck to you in school.

 

[The Pill Counter]

I'm currently working in a tiny dispensary in a medical building, and as you guys might be able to tell, I have a lot of time on my hands. JP, I don't know whether you graduated from pharmacy or not, but in practice, PACtoDOC is right, in certain regards. I don't know more about insulin dosing than an endocrinologist, or even an internist, nor more about card drugs than a cardiologist. True, I'm a bachelors, not a PharmD, but I still highly doubt that a PharmD or myself should be allowed to make therapeutic decisions. How would I evaluate their efficacy? Are patients going to make follow-up appointments in the pharmacy? I think a pharmacy education makes you well-versed in describing drug therapy, monitoring its effect on a patient and reporting their findings to physicians. Hospital pharmacists do this function very well.

Community pharmacy on the other hand, is difficult to describe to those who haven't worked in that environment. For example, one shift in a long term setting two weeks ago, I spent eight straight hours looking at pills in blisters, and signing my name. Sit back for a second and imagine that. Five years of university and I counted pills and checked them off all day. Where did my training come into play there? After a bitter and pride-swallowing two years did I realise that I had become nothing more than what my name suggests. At present I'm locuming at a clinic where I give patients a 30 second run-down of how to take the medication and then ring the prescription through the till.

Again, hospital pharmacy is a whole different ballgame. I haven't spoken to a medical resident yet that hasn't appreciated pharmacy presence and intervention. Hospital pharmacists utilise their education everyday, participate in Pharmacy and Therapeutics Committee meetings, are influential in setting deparmental drug budgets and are at the forefront of new knowledge and innovation. There were drawbacks to hospital work as well. Lower pay than community counterparts being the chief complaint.

Which begs the question, after spending 6+ years getting a PharmD, are you prepared to do what I do? Because there will only be so many hospital jobs in relation to the need in community. I have never meant to disparage pharmacy as a profession, but truly understand what the career will entail. Hell, I'm getting paid a lot of money to sit and post on this thread, while I fill the occasional prescription. All I can say is thank god second year of med school is about to begin, and I've only got a few shifts left.

 

[dgroulx]

Pharm D's are going to write prescriptions. The HMO's don't want to pay for an office visit for a doctor to write a prescription for an antibiotic that the patient didn't need to begin with. Go to another country and you'll find that pharmacists already write prescriptions. It won't be long before that is what happens here. Saving money is more important for the insurance industry.

I'm going into pharmacy because I love chemistry, not because I want to write prescriptions. That will inevitably become part of the job, but it makes no difference to me.

 

[Modnar]

Originally posted by dgroulx
I'm going into pharmacy because I love chemistry, not because I want to write prescriptions. That will inevitably become part of the job, but it makes no difference to me.

That's how I feel too. If I wanted to write scrips and see patients, I'd go to medical school. But I don't want to do those things. I'm more interested in pharmacology and drug development, and that's why I'm planning for a Pharm.D.

 

[PACtoDOC]

I really doubt that you will ever see pharmacists writing prescriptions other than for OTC's. Its just too much territory for physicians to give up, and they won't budge on this one. Physicians don't mind PA's writing scripts because their name is still on it, and the patients are still theirs in the end. Managed care does not have a say how or who writes a prescription, and there is no way you can say that giving pharmacists the ability to prescribe will save the HMO's money. Pharmacists are already like physicians in many ways. They try to appease the sales reps with the deepest pockets. Everyone knows that the biggest push to use generic drugs comes from the pharmacists who often get kick-backs from the generic distributors and the insurance companies. I have even had pharmacists illegally change many ofmy scripts and substitute generics in cases when generics are not even available. Much of my Proventil HFA inhaler script business was chnaged by pharmcists to generic albuterol, but this is actually illegal. Physicians don't have the time or energy to complain to the state board every time this happens, but the truth is it is still illegal. So please don't say that putting prescription power into the hands of pharmacists is going to make the situation any better. Hell, even as a PA, I don't honestly feel that I should have full prescriptive authority. I just think that prescriptions should be left up to physicians only, but that does not mean that I am right. I just have some experience to back up what I am saying.

 

[Dr JPH]

Originally posted by PACtoDOC
Everyone knows that the biggest push to use generic drugs comes from the pharmacists who often get kick-backs from the generic distributors and the insurance companies.

I don't know about kick-backs from these companies directly, but retail pharmacists do get a boat load of bonuses and incentives to increase the generic % of their store.

Some retail chains give cash bonuses or stock to managers and staff pharmacists who work for a store which has the highest % of generic distribution in a particular region or district.

Usually, a percentage goal is set for a particular store and stores that do not regularly meet their pre-set goal often get visits from members of corporate who want to find out first-hand why that is. It can be ugly business.

And PACtoDOC...I would say the number of times that I have seen Proventil HFA to generic Albuterol dispensed is about 1:10.

FYI: I am NOT a pharmacist...I left that game before I finished school...but I spent enough time behind the counter to get a handle on what's going on.

 

[rxgremlin]

As far as for pharmacists changing drugs such as Proventil HFA to albuterol I have never seen anyone do this. Most customers fill their prescriptions at a retail pharmacy and there is no personal incentive for us to change a script. We don't get bonuses or kickbacks to change an rx. We offer generics for the CUSTOMERS! Why make a customer pay up to 5-6 times as much for a Proventil HFA when they've had albuterol in the past? It sounds like PAC to DOC is the one who has bought into the drug reps line of b.s.. I personally have never heard of anyone getting a kick back for generics I work for one of the largest retail chains. That would be unethical & there are unethical pac and rphs. But when asked I certainly would advise to take generic. Did you know that Astra Zenaca makes both tamoxifen and Nolvadex? Or that the same factory that packages proventil makes the generic albuterol? What do you think the difference is in the products? If your too stupid to know that it's just the packaging then mark DAW & make your patients pay the difference.

As far as for Rphs bothering a PA to change drugs due to an allergy, my last genuis PA gave their patient Septra with a sulfa allergy and dosed Tussionex: 2 tsp q 4 hours. I'm sorry that you feel inconvienced by the phone call, and I'm sure that the patient would feel inconvienced by going to the emergency room. If your too blind to see that pharmacist and doctors and pacs all should work together then you are missing the big picture and should consider a new profession. I guarantee that you will make a mistake one day (because we all do)& some rph will save your ass, if you take their call and listen.

 

[Brill]

Please excuse my ignorance of the matter, but why is it to the advantage of pharmacists/pharmacies to promote generic medication?

 

[rxgremlin]

Your question isn't ignorant; your question hits the nail on the head. There is no personal reason for pharmacists to promote
generics other than to save people money. Most people think
that generics are somehow inferior to brand name medications for different reasons. However, when I explain that the difference is only in cost and demonstrate the savings to them, 99% will take the generic. I see no reason in the world for somebody to pay extra for a brand name when a generic is available. Of course there is that always that one person who insists on getting a brand name. I just shrug my shoulders and fill the rx.
Fill a rx, don't fill an rx, brand or generic, no matter what I do I get paid the same.

 

[Dr JPH]

Originally posted by Brill
Please excuse my ignorance of the matter, but why is it to the advantage of pharmacists/pharmacies to promote generic medication?

Retail chains make more money on generics. There is a higher mark-up. Buy cheaper, sell cheaper...but get a bigger cut.

Some in the profession may deny this, but look at the books.

 

[rxgremlin]

Yes, most of the time generics have a larger markup. However,
since most people use insurance for rx and since most insurances work off of Average Wholesale Price (AWP) to figure reimbursement there aren't huge profits. The insurance knows what the drug costs and pays us that cost plus either a dispensing fee and/or a percentage over that cost. So, the patient gets a generic medication that works at the cheapest co-pay that their plan offers. Our average profit is about 20-22%, not unreasonable compared to any other business.

If the patient doesn't have insurance and gets a generic he/she
still saves money. The markup is higher but the savings to the person is still substantial.

I would still like to know how recommending generics to patients to save money is making me rich.

 

[The Pill Counter]

Patented medications sell on the basis of how well the drug company details physicians. Pharmacies have to buy these medications and in most cases, pharmacies are allowed only a tiny markup on these.
In the case of generics, a built-in market for that drug already exists. Generic companies are fighting each other to make sure they are the ones on your shelf. Thus, the success of a generic company resides in their ability to outdo the competition. In this bid, generics offer pharmacies (independent, chain, department store, essentially all of them) discounts, gifts, cashback, 2for1 deals, you name it.
It's deceptive to say that pharmacies do not benefit from having a large percentage of medications dispensed as generic. Patients saving money is a great motivator too, and I've always recommended generic meds as a pharmacist. When I'll be a physician I'll write my scripts generically, and always ask that the lowest priced alternative always be dispensed.

By the way, besides being a pharmacist and in med school, I was a generic drug company rep, so I know a little bit about the behind-the-scenes dealmaking!

 

[LSUMED2006]

I too left pharmacy school before finishing, but I have spent more than enough time behind the counter. Generic medications do make much more money for the pharmacy. I can't count the number of memos, talks, visits from distric managers, etc. that strongly encouraged the use of generics due to the amount of money the store made off of them.

I can also attest to the rampant changing of a brand name drug for generic. In many cases this is best for all involved, but the manner in which it was done did not always follow the law to the letter. Here in LA, as I was getting out of pharmacy, the state legislature passed some law that actually required "DAW" plus a code (I think i remember this correctly) on a script to make it brand name only. Once the law was passed, even if "dispense as written" was checked on the script, pharmacists could sub generic for brand, much to the dismay of some patients and physicians. (we all know phenterimine is only active when called adipex and has blue speckles in the pill).

To MY dismay, patients sometimes requested brand, but the pharmacist found any number of reasons NOT to give it to them. Rather, invariably, generic was substituted due to the fact it made important people money.

Jason

 

[Brill]

So does this mean that the current push towards generics (re: shortening the length of and/or ignoring pharmaceutical companies' patents over certain medications) is actually beneficial to the retail pharmacy chains? I've been told by some people (who admittedly are not extremely knowledgeable is this area) that increasing the use of generics will result in "less money in the system" and would ultimately result in less jobs and lower salaries for pharmacists. Again, please excuse my ignorance in this area.

 

[rxgremlin]

I guess my experiences as a pharmacy manager for the largest grocery chain in America are different than other peoples. I don't get any pressure to promote generics, I don't get bonuses based on generic sales, and I don't dispense generic rx for any other reason than to save people money. Sure, my superiors look at
my profits, my scripts per hour, and the cost of my pharmacy inventory. I don't see many drug reps and when I do I politely listen so I get pens for the pharmacy (we always run out).

Yes, generics offer a higher percentage margin. There is no doubt about it. However, like I said, when I bill an insurance company, I don't get this huge profit. They know what it cost me and reimburse my pharmacy a percentage over cost. I get nowhere near retail price. To explain what I mean, here is a good example: today I filled a Prozac rx. The retail price for the brand is about $100 for a month, the generic is about $50. After billing the insurance, the patient payed a $5.00 copay and the insurance gave us an additional $6.15. So, the insurance didn't reimburse us $45 (plus the customers $5.00), the pharmacy got $11.15. We made a profit, but as you can see it isn't astronomical. I can't stress this enough; insurance dictates what they will pay for, how much they will pay and what the copayment is. I was just happy that the patient only had to pay $5.00. Everybody was happy, we made a profit, the insurance got off cheap, and the customer only had to pay $5.00.

Generics are a win-win-win product. The pharmacy makes a little money, the insurance doesn't have to pay for brand, and the customer gets a good copay. Even if the customer doesn't have insurance, they are much happier getting generics at a fraction of the cost. Which would you rather pay, $50 or $100? So what if the percentage is higher, the customer still pays less. Also, remember that higher profit margins are not the same as total profit. If I sell a ten day supply of generic Keflex ( no insurance)
the profit is about $10.00 if I sell brand the profit is about $35.00.
Alot of generics are like that. Sure, the markup is huge but the total profit is moderate. In any situation the patient pays less, isn't that the important thing?

 

[LSUMED2006]

>lot of generics are like that. Sure, the markup is huge but the total profit is moderate. In any situation the patient pays less, isn't that the important thing?

It sure is very important that the customer pay less. A customer that pays less on drugs is likely to be a repeat customer. However, making a (large) profit is also in my mind nearly as important. Profit is not a dirty word, and the bottom line is that pharmacies are buisinesses. This business mentality is what I have seen many, many times cause the very strong push for generic medications, both in retail as well as independent community pharmacies.


>So does this mean that the current push towards generics (re: shortening the length of and/or ignoring pharmaceutical companies' patents over certain medications) is actually beneficial to the retail pharmacy chains? I've been told by some people (who admittedly are not extremely knowledgeable is this area) that increasing the use of generics will result in "less money in the system" and would ultimately result in less jobs and lower salaries for pharmacists. Again, please excuse my ignorance in this area.

I have forgotten exact statistics, but drug companies must spend several hundred million dollars to bring any new drug to market. Now, consider that around only 3-4/10 drugs brought to market turn a profit, you can see a huge problem for drug companies. We live in a capitalistic society, and drug companies make drugs because it makes them rich, period. Because finding a very marketable, successful medicine is a goldmine for these companies, there is a constant drive towards new and better things in order to make money. I'm rambling here, but back to the point. Drugs must be so expensive initially in order for the drug company to recoup the hundreds of millions of dollars it put in to that drugs creation as well as the other 6-7/10 that did not make any money.

Your friends are right in a sense that if generics were allowed to be used say a year after a drug came to market, then, yes, the system would be in grave danger. THis is why the drug companies have a long patent (7 or more years) in which only they may sell the medication.

However, assuming the drugs patent has expired, using generics makes more money for the patients and drug store. It is also worth noting that many manufacturors make the brand as well as generic medicine.


Jason

 

[indypharmd]

I just have to add one facet to this conversation. Someone had stated that PAs and NPs are more qualified than PharmDs on the basis of their procedural knowledge and time spent in clinical rotations. I can tell you that this is categorially untrue. PharmDs are certainly quite competent in differential dx, the pathophysiological basis of medicine, and therapeutic management of disease states. In order to fully understand and reccomend a course of treatment, the PharmD has to be well-versed in the pathophysiological/pathological basis of disease in order to reccomend correct and therapeutic treatment. There are many PAs and NPs who are more than capable of preforming clinical procedures but are entirely reliant on a PDA to prescribe appropriate medicinal therapy. I venture to say that this as well goes for MDs judging by the amount of prescribing errors that are made in clinical settings. The other and more important point here is that there was some talk of "years of education" being a factor in terms of competency. What do you say to the PharmD who has done both a PGY1 and PGY2 residency in an area such as hematology/oncology or psychopharmacology or pharmacotherapy and then continues on to become board certified in their disciplines? Would you still say that they are not the equal of an MD, not to mention a PA, in terms of clinical experience, disease state mangement. therapeutic care plan management and competency? I can guarantee you they are.
I think that the greater point here is that healthcare professionals should work together to combine their strengths to the benefit of the patient rather than engage in a pissing contest over status or prestige.
Just my thoughts.

 

[confettiflyer]

Your first post, and you dig up a 6 year old thread and write that?

 

[fhx06]

We as professionals should be treating each other with respect because we all need each other in order to better the life of the patients we care for. Having worked in a hospital, I see the negativity and the hostility that can come about between various professions... and even between departments. The fact of the matter is, we are all part of a team that has to work together so that the living person who is entrusting us with his or her life will remain living and be better for it.

 

[tackett26]

I've done a complete history and physical examination as part of my PharmD training. I am also a former member of the Infectious Disease Molecular Diagnostics Committee and have successfully designed several diagnostic assays. How many have you designed?

.

Exactly how do these PharmD's get the same patient care contact as NP's and PA's? I have yet to see a PharmD student do a complete history and physical, write an entire set of admission orders and make daily progress notes and patient visits. Exactly where do you get this training? Where do you learn to read x-rays, perform thoracentesis, and perform minor procedures? Where exactly do you do these rotations that are just like NP and PA school?