Ontario Medical Association On Solo NPs, Prescribing Pharmacists, "Gatekeepers"

The same thing is on the verge of happening here. The idea of pharmacists prescribing really disturbs me. How the hell can you prescribe without a diagnosis first? That's ridiculous. And with the frequency to which family docs overuse anitbiotics, I can only imagine the kind of antibiotic resistance we would begin to see with every Dick, Jane, and Harry showing up at their pharmacy for some free Cipro every time they have a sneeze or sniffle.

I didn't know you had free Cipro in the US. We don't in Canada.

The Canadian Pharmacist Association's position statement on pharmacist prescribing:

Pharmacist prescribing includes a wide range of activities, such as:
- prescribing over-the-counter and prescription drugs to treat minor, self-diagnosed or self-limiting disease conditions
- providing emergency supplies of prescribed medication to a patient
- monitoring and authorizing the refill of existing prescriptions to ensure appropriate and effective care
- modifying a prescription written by another prescriber to alter dosage, formulation, regimen or duration of the prescribed drug
- modifying a prescription written by another prescriber to provide a therapeutic alternative to improve drug therapy or provide continuity of therapy
- prescribing medications for patients through delegated authority and collaborative practice agreements, or by using protocols as established by institutions or jurisdictions
- initiating or discontinuing a medication where the pharmacist, in collaboration with the physician and/or other health care professionals, provides comprehensive drug therapy management.

Pharmacists have long had a prescriber role in the institutional setting in Canada, where they make significant contributions to the quality of drug therapy and patient outcomes by initiating, monitoring and adjusting drug therapy. Currently in the community setting, pharmacists assess and triage patients for chronic and self-limiting conditions, and assess, recommend and monitor prescription and non-prescription drug therapy for thousands of Canadians each day.

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Pharmacists have not had a longstanding role in drug decisions in the US, especially retail pharmacists, which is why they don't have the first damn clue about diagnosing anything. As far as your crack about free Cipro, you know what I'm talking about. People would be lined up at the door every time they were sick expecting the pharmacist to hand them some antibiotics really quickly. Are you suggesting to me that you don't believe antibiotics are overused, or that you don't see that as a problem? I once had a pharmacist (retail) mention benign prostatic hypertension to me, so I rest my case that they no little about disease processes, or even the names of them. My understanding is that pharmacists learn about pharmacology, pharmacokinetics, etc, which is why they should stick with that instead of diagnosis and prescribing. My understanding about nursing school is that it primarily teaches nursing, rather than diagnosis, which is probably why nurses should stick to nursing. By the way, yes United Supermarket pharmacies in Texas offer free Cipro, with a prescription of course

I suggest you read this thread.

I already have. I posted on it. I respect pharmacists totally. I just don't think they should be diagnosing and prescribing independently. In a hospital setting, a clinical pharmacist manages dosages AFTER a physician has diagnosed and with a physician monitoring the overall health of the patient. I don't have a problem with clinical pharmacist input, nor do I have a problem with retail pharmacist input about drug selection. I just don't think pharmacists are qualified to determine from scratch whether someone needs a certain drug, and I don't think people should be able to just walk in and ask for whatever they want. Are you telling me that you would feel comfortable with a patient walking into a retail pharmacy and asking for an antibiotic and just getting one for a sore throat without a strep test or any kind of diagnostics whatsoever?

RGMSU said:

I already have. I posted on it. I respect pharmacists totally. I just don't think they should be diagnosing and prescribing independently. In a hospital setting, a clinical pharmacist manages dosages AFTER a physician has diagnosed and with a physician monitoring the overall health of the patient. I don't have a problem with clinical pharmacist input, nor do I have a problem with retail pharmacist input about drug selection. I just don't think pharmacists are qualified to determine from scratch whether someone needs a certain drug, and I don't think people should be able to just walk in and ask for whatever they want. Are you telling me that you would feel comfortable with a patient walking into a retail pharmacy and asking for an antibiotic and just getting one for a sore throat without a strep test or any kind of diagnostics whatsoever?

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Prescribing without a diagnosis is stupid. However, I think the system might work a little better if we had physicians and pharmacists working as a team. Physician provide the diagnosis then the pharmacist handle therapy. That includes prescribing medication and monitoring the therapy. If the patient isn't responding to one therapy the pharmacist can quickly adjust it.

Like it or not pharmacists roles will begin to expand if medicine goes the way they has been esp. once pharmacogenomics and medication therapy go full force. That's not a bad thing. It's less headache from a physician's perspective. They just go in an diagnose. Then keep up with the medical team. The team base approach is what I emphasize. it doesn't make sense to force physicians' to take all the responsibilities, especially when they have members on their team that are better trained than they are in medication therapy. That's like seeing a cardiologist when you need an oncologist. It's true the cardiologist has had some training in oncology, and he has some good advice, but he's not the BEST resource on oncology. Get my point?


Obviously it doesn't make sense to have a retail pharmacist prescribing. Diagnosis isn't just you listening to what a patient thinks it is and then acting on that. You have to know what tests to run, then you have to put all the results together along with your training to find out what it's wrong. It's like being a detective or an mechanic there are lots of internals you need to know. However knowing that the engine is messed up, doesn't mean your the best person to replace it. There maybe a someone that is quicker than you at removing that engine and putting in a new one, and will make fewer mistakes doing it.

There is some sense in what you say. However, with the current focus on cost of healthcare, it seems unlikely that we will be adding additional services rather than taking them away. As soon as a clinical pharmacist gets the opportunity to prescribe and manage, they will then want to be paid per patient. So, if you have a physician continuing to oversee as you put it, plus a clinical pharmacist managing medicines, then you are paying for two highly educated professionals, instead of one. In my experience, pharmacists don't expect to work for cheap, neither do physicians. If the physician is just used for diagnosis and then thrown off the case, that makes the physician somewhat irrelevant, and is not a good use of a physician's education, since one of your arguments is that pharmacists not prescribing is a poor utilization of their education. I don't see why pharmacists can't be used for consult, while the physician continues to manage. I think that is the best utilization of the two areas of expertise. And these residency trained PharmDs you're talking about, while in my experience they are QUITE few and far between, how are they going to fit into outpatient medicine? Seems more like a plan for inpatient medicine to me. In my experience, most hospital PharmDs are not residency trained at all, so I doubt you're going to find much of this expertise at any hospitals other than the largest academic training centers. Finally, who will make the final decision and bear the ultimate responsibility? If the pharmacist and the physician disagree on a treatment plan, are you telling me that the pharmacist is willing to accept legal responsibility in contravening the physician if the pharmacist is incorrect? Seems like a pretty bold move. Pharmacists have not had the experience of being a legal target like physicians have, but as you become more high profile, if that occurs - well, just watch out for the malpractice insurance premiums and lawyers lurking over your shoulders. Lots of physicians pay tens of thousands of dollars annually for malpractice coverage. Is that what pharmacists are looking for too?

In Canada, a good number of the provinces now allow pharmacists to prescribe. Ontario is just following that trend.
In many other countries, there is a pharmacist only class of medications.
Most pharmacists are blind to the cost of malpractice insurance. The clear cut majority are employed by someone else. They pay the primary insurance. A pharmacist can purchase a secondary policy. A secondary $1 million/$3 million policy will run about $200 per year.

That's my point. In America at least, I would expect malpractice insurance will become significantly higher than $200 a year as soon as pharmacists become higher profile for lawsuits as they make more prescribing decisions. It is not appropriate for the pharmacist to make the prescribing decision and the physician to be legally acted upon because of the consequences of the decision. At the moment, pharmacists are rarely sued, hence malpractice rates are low. As they take on more responsibilities, it would follow by necessity that they would become the subject of more lawsuits. If pharmacists become the principal prescribers, and if you think physicians won't let patients know that, you're wrong. The first time the patient points the finger at the physician when a pharmaceutical problem arises, the physician will quickly point the finger at the pharmacist if the decision was made by him/her. If you think patients and lawyers in America won't look to sue you if you're the principal prescriber, you're also wrong. If you think someone else will continue to pay your malpractice insurance if the price creeps up, you will probably be wrong on that one too. Also, if you are the prescriber, like I have already said, you must be available to the nursing staff to discuss issues with that prescription as such issues arise. That's why every doctor has a cell phone in their pocket all the time. Welcome to the real world of prescribing and its consequences. It's not just scribbling on the chart and then skipping off to home carefree for the weekend.

Pharmacists do a lot more than count pills. It was never my intention to impugn the integrity or severity of their work. I was merely calling into question what the scope of the work should be. I actually think pharmacists are quite good at getting the fine details. They rarely miss something, whether it be a letter of the law (most docs aren't too good with prescribing law) or an expiration date. I like having a pharmacist checking over each prescription that goes through, whether in an inpatient or outpatient setting. That's another concern about pharmacists becoming prescribers. Who then will be doing the verification process? Any physician or pharmacist will tell you that someone checking their own work is typically a bad idea. So, what, you have one pharmacist prescribing and another verifying? That's going to require a lot more pharmacists than we have at the moment. In case you haven't noticed, there's just as big a shortage of pharmacists as there is of physicians.

Most physicians don't want to deal with dispensing medications. Unless you have about 100 prescriptions a day, you won't break even. It is not uncommon that you will loose money on some prescriptions. If you break any aspect of the pharmacy law, it can easily be a $10,000 fine. Establishing a drug inventory is very expensive.

nolagas said:

Doctors have traditionally not prescribed and dispensed medicine for improved safety and removing conflicts of interest. I think that was a fine rule. Are pharmacists just superior morally and professionally so that they can safely diagnose (which they obviously aren't trained to do), prescribe, and dispense the meds?

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I am in agreement with the concept of separation of roles and checks and balances. You are correct - if it is inappropriate for physicians to both prescribe and dispense, it should be equally inappropriate for pharmacists to do both. I also agree that, with the focus on pharmacology in the PharmD program, there is little room for a focus on diagnosis. I think it would be nice in the discussion of healthcare reform if, instead of completely up-ending the system and totally redefining everyones' roles, we would just make the minor changes that need to be made to improve upon the positive things that exist in American healthcare.

Until a bit more than 100 years ago, the role of the pharmacist and physician was not well differentiated. The AMA and the APhA sat down agreed to the separation of the roles. Since then, pharmacists have not been involved in prescribing and physicans have mostly stayed away from dispensing.

genesis09 said:

Until a bit more than 100 years ago, the role of the pharmacist and physician was not well differentiated. The AMA and the APhA sat down agreed to the separation of the roles. Since then, pharmacists have not been involved in prescribing and physicans have mostly stayed away from dispensing.

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So we should go back to the days 100 years ago where everybody was selling homemade snake oil out of a covered wagon?

genesis09 said:

Until a bit more than 100 years ago, the role of the pharmacist and physician was not well differentiated. The AMA and the APhA sat down agreed to the separation of the roles. Since then, pharmacists have not been involved in prescribing and physicans have mostly stayed away from dispensing.

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A lot's changed in medicine in the last 100 years and the majority of pharmacists in the US today work in retail stores like Walgreens and Walmart.