AMA scope of practice data series: pharmacists

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drhenPharmD

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In a article published by the AMA scope of practice data series earlier this year, role of pharmacists today are harshly criticized.


“Neither the practice experiences nor the didactic component of the pharmacist education prepares a pharmacy student to develop the clinical judgment similar to a physician …with regard to the diagnosis, assessment of
illness/condition, formulation of a treatment plan, or the provision of independent medical care or medication therapy.”

“To protect patients’ health and safety, physicians considering entering into CPAs with pharmacists should assess whether the education, training, and expertise of a pharmacist adequately equips him or her to initiate, monitor, and/or modify therapeutic regimens prescribed by physicians”

These are just a few quotes. Its a publication intended for internal use only but these quotes were released by one of the american pharmacy institutions. Has anyone else seen this yet? The ASHP, ACPE and a bunch of other pharmacy organizations have rebutted to have the AMA amend or rescind the article (which are used by state and federal associations to make regulations and stuff) but they haven't done so yet.

I know there's a bunch of pharmacists vs doctors debates on here, and I don't want to start another one. I just don't think this article is fair, and I feel the AMA should know better. Especially when the ACPE standards meet a lot of what the AMA are saying we don't have. The best decision for the patient is always one that has been derived by the collaboration of the entire health care team.

sorry if there are grammer errors, I typed this really quickly
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AMA's primary interest is to protect MDs and stop encroachment by other health care professions.
 
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meister said:
The AMA is right, pharmacists aren't diagnosticians. They don't need to be.
Click to expand...

Yes, but we're pretty good at "formulating a treatment plan". And they aren't right in the fact that collaborative practice agreements with pharmacists are evil.
 
And then you have all of the studies that say the inclusion of pharmacists in pharmacotherapy decisions improves outcomes.

....

Can't blame the AMA for resisting change. 20 years ago physicians were all little dictators, commanding the actions of their underlings as if everyone else lived to serve them. And now you expect them to take a team approach? Admit that they aren't the all-knowing expert on everything? They've got an image to uphold.
 
WVUPharm2007 said:
And then you have all of the studies that say the inclusion of pharmacists in pharmacotherapy decisions improves outcomes.
Click to expand...
These studies are like a-holes. Everyone's got them.

Most of these outcome studies are flawed. They're like education and sociology studies; every decade has a new flavor.
 
Maybe I should get an AMA membership after all, looks like they're finally coming to their senses and seeing the threat of all these noctors, pharctors and optometrists who made bad career decisions now trying to encroach into the physician's scopes of practice.
 
naus said:
These studies are like a-holes. Everyone's got them.

Most of these outcome studies are flawed. They're like education and sociology studies; every decade has a new flavor.
Click to expand...

care to expand on this?
 
naus said:
Maybe I should get an AMA membership after all, looks like they're finally coming to their senses and seeing the threat of all these noctors, pharctors and optometrists who made bad career decisions now trying to encroach into the physician's scopes of practice.
Click to expand...


:laugh::laugh::laugh::laugh:
Love the physician arrogance. "If you aren't a physician, then you have a bad career"
 
naus said:
These studies are like a-holes. Everyone's got them.

Most of these outcome studies are flawed. They're like education and sociology studies; every decade has a new flavor.
Click to expand...

No, not really. The worst study I've ever read with pharmacist collaborative practice agreements led to no significant improvement in hyperlipidemia patients. Diabetes, asthma, hypertension...there are several other very well designed studies that have proven pharmacist involvement in therapy improves outcomes. The most famous of which is the Asheville Project. And that was back in the 90s. Going on two decades later, pharmacists are still improving outcomes and saving costs. That's why insurance companies like WV PEIA are actually requiring patients to meet with pharmacists for disease management interviews.

...

Not that I care...I'm not interested in it...
 
The cashier at my pharmacy go a skin infection that was cultured as MRSA and she brought in a prescription from her MD for Pen-VK..........certainly better at formulating a treatment plan.

Then there was the phone call yesterday from a physician calling in Lovenox for pt with a dose of 25mg SQ daily for DVT prophylaxis.

Me: 25mg??, Aren't you writing this for DVT prophylaxis?
Dr: Isn't that the recommended dose?
Me: No, it's actually 40mg daily
Dr: Oh, but he has renal insufficiency
Me: What is his CrCl?
Dr: 1.2
Me: Is he on dialysis?
Dr: No
Me: His CrCl is 1.2 or his SCr is 1.2?
Dr: Oh, SCr...
Me: Then he really doesn't have renal insuficiency (30 yo M pt.)
CHEST guidelines recommend 40mg daily for DVT prophylaxis, do you want to give him 40
Dr: How much is it if I give him 25mg BID
Me: <sigh> well, the lowest dose it comes in is 30mg, about $450
Dr: Really!!!!!!!!!! Let's just give him SQ heparin
Me: Ok, 5000 units TID?
Dr: No, just 5000 units once daily
Me: pistol in mouth, must kill myself
 
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kvl1027 said:
The cashier at my pharmacy go a skin infection that was cultured as MRSA and she brought in a prescription from her MD for Pen-VK..........certainly better at formulating a treatment plan.

Then there was the phone call yesterday from a physician calling in Lovenox for pt with a dose of 25mg SQ daily for DVT prophylaxis.

Me: 25mg??, Aren't you writing this for DVT prophylaxis?
Dr: Isn't that the recommended dose?
Me: No, it's actually 40mg daily
Dr: Oh, but he has renal insufficiency
Me: What is his CrCl?
Dr: 1.2
Me: Is he on dialysis?
Dr: No
Me: His CrCl is 1.2 or his SCr is 1.2?
Dr: Oh, SCr...
Me: Then he really doesn't have renal insuficiency (30 yo M pt.)
CHEST guidelines recommend 40mg daily for DVT prophylaxis, do you want to give him 40
Dr: How much is it if I give him 25mg BID
Me: <sigh> well, the lowest dose it comes in is 30mg, about $450
Dr: Really!!!!!!!!!! Let's just give him SQ heparin
Me: Ok, 5000 units TID?
Dr: No, just 5000 units once daily
Me: pistol in mouth, must kill myself
Click to expand...

Where do you work that you're getting DVT prophy prescriptions called in? I don't think I've ever heard of that outside of long-term care facilities (and hospitals, obviously).
 
Praziquantel86 said:
Where do you work that you're getting DVT prophy prescriptions called in? I don't think I've ever heard of that outside of long-term care facilities (and hospitals, obviously).
Click to expand...

I work at an Independent pharmacy that also does IV infusions for home health. So sometimes we get scripts for DVT prophylaxis for home health patients. Not that often, but it happens on occasion. We primarily fill IV antibiotics, so it is kind of nice to be a retail pharmacist that gets to do infusion and PK stuff. It keeps things interesting.

Although, sometimes it is difficult to get the physicians who, according to AMA, are so much more qualified to apply medication therapy to do things more appropriately. We have a patient is on Vanco 1g Q24H without any indication and trough of 7. The doc wont stop the vanco, and won't increase the dosing schedule to bring the trough up to a more therapeutic level. What do I know?
 
kvl1027 said:
Me: What is his CrCl?
Dr: 1.2
Me: Is he on dialysis?
Dr: No
Click to expand...
If not for the clarification that he meant SCr, we'd have perhaps the worst treatment plan of all.
 
drhenPharmD said:
In a article published by the AMA scope of practice data series earlier this year, role of pharmacists today are harshly criticized.


“Neither the practice experiences nor the didactic component of the pharmacist education prepares a pharmacy student to develop the clinical judgment similar to a physician …with regard to the diagnosis, assessment of
illness/condition, formulation of a treatment plan, or the provision of independent medical care or medication therapy.”

“To protect patients’ health and safety, physicians considering entering into CPAs with pharmacists should assess whether the education, training, and expertise of a pharmacist adequately equips him or her to initiate, monitor, and/or modify therapeutic regimens prescribed by physicians”

These are just a few quotes. Its a publication intended for internal use only but these quotes were released by one of the american pharmacy institutions. Has anyone else seen this yet? The ASHP, ACPE and a bunch of other pharmacy organizations have rebutted to have the AMA amend or rescind the article (which are used by state and federal associations to make regulations and stuff) but they haven't done so yet.

I know there's a bunch of pharmacists vs doctors debates on here, and I don't want to start another one. I just don't think this article is fair, and I feel the AMA should know better. Especially when the ACPE standards meet a lot of what the AMA are saying we don't have. The best decision for the patient is always one that has been derived by the collaboration of the entire health care team.

sorry if there are grammer errors, I typed this really quickly
Click to expand...


bottom line: Job security! MD providers want job security too ..just like anyone else...
 
gotdrugs said:
:laugh::laugh::laugh::laugh:
Love the physician arrogance. "If you aren't a physician, then you have a bad career"
Click to expand...

Laugh all you want, but your own actions validate it. Ask yourself why it is that all these "health care providers" want into our turf? Its because you envy us and you want our $$$$.
 
Socrates25 said:
Laugh all you want, but your own actions validate it. Ask yourself why it is that all these "health care providers" want into our turf? Its because you envy us and you want our $$$$.
Click to expand...

Pharmacists that do MTM and disease management counseling don't make any more money. The reimbursement rates out there are about $60/hr or so...about enough for a pharmacist salary and a bit off the top for the Corporate monster employing the pharmacist. That's pretty much a null argument.

I have no interest in it personally...but to ignore that these programs reduce costs and improve outcomes would be pretty stupid of the insurers that pay for them.

Yes, you're a physician...or going to be a physician. Good for you. I'm sure your parents are proud. But the people paying for healthcare don't particularly care and if a program exists that costs less money without negatively affecting patient care, they will roll it out every time. Not that I see why you care...it's considered a "value added" service that runs independent of the physician-patient relationship, anyway.

It's a pretty stupid argument to be having in the first place.
 
Socrates25 said:
Laugh all you want, but your own actions validate it. Ask yourself why it is that all these "health care providers" want into our turf? Its because you envy us and you want our $$$$.
Click to expand...


Right...like those primary docs doing their own dispensing to take pharmacy $$$$.
 
The AMA is a political self-serving organization that's more concerned about its members wallets than the welfare of patients. However, with regard to the education we PharmD's receive... it sucks balls. We all know this and complain about it on the forum constantly. The first year is like undergrad redux and allot of the curriculum is left over from an age when most druggists actually made drugs. Rather than bicker over whose turf it is anyway we should support higher clinically minded education standards so that no one can ask questions when we are taking on more patient care responsibilities.
 
Mariachi said:
The AMA is a political self-serving organization that's more concerned about its members wallets than the welfare of patients. However, with regard to the education we PharmD's receive... it sucks balls. We all know this and complain about it on the forum constantly. The first year is like undergrad redux and allot of the curriculum is left over from an age when most druggists actually made drugs. Rather than bicker over whose turf it is anyway we should support higher clinically minded education standards so that no one can ask questions when we are taking on more patient care responsibilities.
Click to expand...

I agree that first year "sucks ball", but after that my education was very highly clinically minded.

It would be nice if their was one pharmacy organization that spoke for the pharmacist's behalf instead of several organizations having a pissing contest over which "type" of pharmacist is more important.
 
Sparda29 said:
Nah, in the intensive/critical care unit just sitting around from 8AM-4PM, with my iPod out and just monitoring patient's drug therapies and sending occasional recommendations.
Click to expand...

What fantasy world do you live in?
 
kvl1027 said:
I agree that first year "sucks ball", but after that my education was very highly clinically minded.

It would be nice if their was one pharmacy organization that spoke for the pharmacist's behalf instead of several organizations having a pissing contest over which "type" of pharmacist is more important.
Click to expand...


+1+1+1

I read the ASHP response. What biatches! Sometimes I wonder why I renew my ASHP membership.

And I'm definitely not renewing APhA this year.
 
ThePlantation said:
+1+1+1

I read the ASHP response. What biatches! Sometimes I wonder why I renew my ASHP membership.

And I'm definitely not renewing APhA this year.
Click to expand...

Wow, what a completely lame response. The response was intended to be somewhat in my defense and I grew tired of reading. This is exactly what I was talking about. We don't need three different pharmacy organizations sending a letter asking for an apology or retraction. ASHP basically said, we can't speak for retail pharmacists, but......... Why does their have to be a distinction between the two disciplines, when the AMA is making a generalized statement about our "sub-par" education?

I understand what the AMA's goal is by this statement, job security, I get that. But making an incorrect blanket statement about our general lack of education and ability is just plain wrong and they don't need some long drawn out explanation, to be told they need to fix it.

I think there needs to be one main pharmacy association that speaks for the profession as a whole and would send a letter to the AMA that says, you screwed up, now fix it.

-Future President of the AANBSP (American Association of No Bull S**t Pharmacists)
 
drhenPharmD said:
In a article published by the AMA scope of practice data series earlier this year, role of pharmacists today are harshly criticized.


"Neither the practice experiences nor the didactic component of the pharmacist education prepares a pharmacy student to develop the clinical judgment similar to a physician &#8230;with regard to the diagnosis, assessment of
illness/condition, formulation of a treatment plan, or the provision of independent medical care or medication therapy."

"To protect patients' health and safety, physicians considering entering into CPAs with pharmacists should assess whether the education, training, and expertise of a pharmacist adequately equips him or her to initiate, monitor, and/or modify therapeutic regimens prescribed by physicians"

These are just a few quotes. Its a publication intended for internal use only but these quotes were released by one of the american pharmacy institutions. Has anyone else seen this yet? The ASHP, ACPE and a bunch of other pharmacy organizations have rebutted to have the AMA amend or rescind the article (which are used by state and federal associations to make regulations and stuff) but they haven't done so yet.

I know there's a bunch of pharmacists vs doctors debates on here, and I don't want to start another one. I just don't think this article is fair, and I feel the AMA should know better. Especially when the ACPE standards meet a lot of what the AMA are saying we don't have. The best decision for the patient is always one that has been derived by the collaboration of the entire health care team.

sorry if there are grammer errors, I typed this really quickly
Click to expand...

Forgive me, but I'm really curious to know exactly which portion of those quotes you disagree with. You just said you don't think it's fair because ACPE standards meet what the AMA denies-- which ones? How? Exactly what is incorrect or unfair?

I invite others to respond as well.
 
Sparda29 said:
Nah, in the intensive/critical care unit just sitting around from 8AM-4PM, with my iPod out and just monitoring patient's drug therapies and sending occasional recommendations.
Click to expand...

It's statements like that that make the docs look at us funny in the first place. They're busting their asses all day to take care of patients, and you want to sit like a unit secretary (with less work). I would be pissed at pharmacists too.
 
Praziquantel86 said:
It's statements like that that make the docs look at us funny in the first place. They're busting their asses all day to take care of patients, and you want to sit like a unit secretary (with less work). I would be pissed at pharmacists too.
Click to expand...

Oh there's plenty of work to be done, it's just a lot more chilled and relaxing than the retail mess.
 
illegallysmooth said:
Forgive me, but I'm really curious to know exactly which portion of those quotes you disagree with. You just said you don't think it's fair because ACPE standards meet what the AMA denies-- which ones? How? Exactly what is incorrect or unfair?

I invite others to respond as well.
Click to expand...

If you have time, please take a look at our ACPE standards.
http://www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf

Standard no. 12 disagrees with the AMA statement that we cannot formulate a treatment plan at a clinical level similar to that of a physician.

Standard no. 13 details our curriculum standards. In my opinion, it adequately equips us to initiate, monitor, and/or modify therapeutic regimens prescribed by physicians. The med students that I've spoken to at my school also agree.

I don't have time to look through the entire set of standards but I'm sure if I did there would be more discrepancies. I believe most of the major pharmacy associations sent letters to the AMA. I'm sure their letters will have more exact evidence for what was incorrect and unfair.
 
drhenPharmD said:
If you have time, please take a look at our ACPE standards.
http://www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf

Standard no. 12 disagrees with the AMA statement that we cannot formulate a treatment plan at a clinical level similar to that of a physician.

Standard no. 13 details our curriculum standards. In my opinion, it adequately equips us to initiate, monitor, and/or modify therapeutic regimens prescribed by physicians. The med students that I've spoken to at my school also agree.

I don't have time to look through the entire set of standards but I'm sure if I did there would be more discrepancies. I believe most of the major pharmacy associations sent letters to the AMA. I'm sure their letters will have more exact evidence for what was incorrect and unfair.
Click to expand...

I don't think that the AMA statement and Standard #12 are mutually exclusive. Once a diagnosis is in place, can you folks formulate a medication treatment plan? Heck yes, possibly even better than we can. Where I'm at, pharmacy completely manages certain types of infections, all we do is say "Here's the culture and sensitivities, do what you think needs doing". I love it. If its a lab based dx and lab based tx, I bet y'all can diagnose and treat with the best of them. For all I know, you could be pretty fair hands at xrays as well. Does that mean that you are our equals at every aspect of a treatment plan? I don't honestly know, but I'm doubtful. For sports physicals, do you know what to look for and when a EKG/ECHO is warranted for potential HCM? Are you intimately familiar with the new cervical cancer guidelines, both screening, dx, and tx? How do you decide which of the multitude of tests to give someone with chest pain? What do you know when a child isn't hitting his/her developmental milestones, and how much delay is acceptable before you need to refer to a specialist?

To my mind, PharmDs are the drug wizards. I'll never be your equals in that realm. You've even expanded to making the treatment plans in many cases, often doing a better job than many MDs. Your exam skills might even be good enough to manage conditions not solely lab based, I don't know but it sure seems plausible. Does that make you my equal in formulating all treatment plans? I'm sorry, I just don't think it does.

Now obviously if the AMA is solely talking about medication therapy plans, I can certainly see where you're coming from and then let's all just pretend my post never happened.
 
VA Hopeful Dr said:
I don't think that the AMA statement and Standard #12 are mutually exclusive. Once a diagnosis is in place, can you folks formulate a medication treatment plan? Heck yes, possibly even better than we can. Where I'm at, pharmacy completely manages certain types of infections, all we do is say "Here's the culture and sensitivities, do what you think needs doing". I love it. If its a lab based dx and lab based tx, I bet y'all can diagnose and treat with the best of them. For all I know, you could be pretty fair hands at xrays as well. Does that mean that you are our equals at every aspect of a treatment plan? I don't honestly know, but I'm doubtful. For sports physicals, do you know what to look for and when a EKG/ECHO is warranted for potential HCM? Are you intimately familiar with the new cervical cancer guidelines, both screening, dx, and tx? How do you decide which of the multitude of tests to give someone with chest pain? What do you know when a child isn't hitting his/her developmental milestones, and how much delay is acceptable before you need to refer to a specialist?

To my mind, PharmDs are the drug wizards. I'll never be your equals in that realm. You've even expanded to making the treatment plans in many cases, often doing a better job than many MDs. Your exam skills might even be good enough to manage conditions not solely lab based, I don't know but it sure seems plausible. Does that make you my equal in formulating all treatment plans? I'm sorry, I just don't think it does.

Now obviously if the AMA is solely talking about medication therapy plans, I can certainly see where you're coming from and then let's all just pretend my post never happened.
Click to expand...


Yes we are drug wizards. To my knowledge we also learn multiple treatment plans for many different diagnoses, whether or not they are medication therapies. Once a patient has been diagnosed, we should be able to development a treatment plan. (I'm not there yet so I don't know for sure, but this is what I've heard from P4s and pharmacists)

I would also like to add that standard #12 also disagrees with the AMA statement that pharmacists cannot, at the same level of physicians, provide medication therapy.
 
We have different organizations because most retail pharmacists are different from hospital pharmacists. You can even argue that outpatient hospital ones are different from the inpatient ones that manage medication therapies. This is what I think should happen.

Pharm D + BCPS certified (inpatient hospital pharmacist, academia, clinic under protocol, etc) = Regular pharmacist duties + independent prescriptive authorities under protocol

Pharm D (retail, outpt hospital, etc) = Regular pharmacist duties and that's it!

If we do this, then the pharmacists that have done residencies and want that "clinical" job can have what they want, and get a little more recognition for having special training. The people that just want to do retail can still get out in 4 years and work.
 
VA Hopeful Dr said:
Does that make you my equal in formulating all treatment plans? I'm sorry, I just don't think it does.
Click to expand...

I think most people in this forum would agree with this statement. Pharmacists are not familiar enough with diagnostic techniques and in general the patients history (usually) to completely formulate a treatment plan. It seems the AMA is taking it to a different level by saying we don't have the knowledge to be involved with monitoring and modifying therapeutic treatment plans, which is pretty much becoming the point of emphasis of our degree. Initiating therapy is another situation as like I said before, not having the diagnostic knowledge/patient history is HUGE in initiating therapy. This may or may not be true for all schools but I know at my pharmacy school we learn a lot about patient interviewing and even patient histories. Not saying that grads of my school can hang with physicians in terms of diagnosing but in certain situations we certainly can help.
 
tungsten87 said:
I think most people in this forum would agree with this statement. Pharmacists are not familiar enough with diagnostic techniques and in general the patients history (usually) to completely formulate a treatment plan. It seems the AMA is taking it to a different level by saying we don't have the knowledge to be involved with monitoring and modifying therapeutic treatment plans, which is pretty much becoming the point of emphasis of our degree. Initiating therapy is another situation as like I said before, not having the diagnostic knowledge/patient history is HUGE in initiating therapy. This may or may not be true for all schools but I know at my pharmacy school we learn a lot about patient interviewing and even patient histories. Not saying that grads of my school can hang with physicians in terms of diagnosing but in certain situations we certainly can help.
Click to expand...

I think part of the issue here is that pharm people tend to make statements (like above) equating treatment to DRUG treatment, and then medical people want to point out all the other parts of the story. Obviously pharm guys and gals are the DRUG wizards, but when it comes to full diagnostic and treatment plans OTHER than pharmaceuticals, I don't think the pharmacy education is sufficient (nor should it be, otherwise they should just call it medical school on steroids).

I completely agree that pharmacists should be involved in managing patients' drug therapies in any complex situation and with long term lab monitoring and adjustment. However, I'm sure the AMA is trying to keep diagnosis and work-up in physician territory.
 
illegallysmooth said:
I think part of the issue here is that pharm people tend to make statements (like above) equating treatment to DRUG treatment, and then medical people want to point out all the other parts of the story. Obviously pharm guys and gals are the DRUG wizards, but when it comes to full diagnostic and treatment plans OTHER than pharmaceuticals, I don't think the pharmacy education is sufficient (nor should it be, otherwise they should just call it medical school on steroids).
Click to expand...

good point there. we don't even take anatomy (glad I had it in undergrad) and definitely aren't qualified for a lot of physical-related therapies.
 
drhenPharmD said:
What pharmacy school do you go to? The majority of pharmacy students, including myself, take at least one semester of anatomy.
Click to expand...

actually... my school does require anatomy :X

i will say that a lot of anatomy courses are not on the medical school level. my undergrad anatomy course was taught by an MD and while the course was intense, it wasn't quite med school level as we didn't have to know origins/insertions, brodmann areas, etc.
 
drhenPharmD said:
What pharmacy school do you go to? The majority of pharmacy students, including myself, take at least one semester of anatomy.
Click to expand...

Our school requires Anatomy and Physiology as a prerequisite, therefore they don't even really talk about Anatomy and they barely talk about physiology before jumping into pathophysiology.
 
right about the physical part cause frankly i don't think many pharmacy school a&p class are too concerned with gross anatomy but more so with physiology.

"with regard to the diagnosis, assessment of
illness/condition, formulation of a treatment plan, or the provision of independent medical care or medication therapy.”

-we don't do diagnosis, nor assess illness/condition.
-but treatment plan based on pharmaceutics and medication therapy, that we do.

silly docs
 
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