Are we too apathetic?

[ChasingMyDreams]

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So...recently a professor posed a very interesting series of questions to our class...What would our ideal practice model be? Is that practice model in effect anywhere currently? What are we willing to do about it? You can imagine the variety of answers to the first question but there was an almost unanimous no and nothing to the second two...so here are my two cents and I would appreciate it if you would follow with yours...I have worked in a hospital system (large teaching hospital) for almost two years...I have seen clinical pharmacy in action...I have also rotated through retail...my conclusion? Very few pharmacists are being utilized to their full capacity...I cannot speak for everywhere but I have shadowed at a couple of very progressive, prestigious institutions and although they did more than other facilities, there was still a great deal of room for improvement....so operating under the assumption that generally pharmD's are the experts in drug therapy, is it reasonable to conclude that in an ideal practice model, physicians/pa's/np's would be reponsible for diagnosis and non-pharmacological treatment and pharmd's (residency trained of course) would be reponsible for pharmacological therapy? And on the retail side shouldn't there be more of an MTM approach to each patient? Clearly this isn't the case at very many institutions, so why aren't we fighting for it? Would it not create more jobs and at least eliminate some of the gloom and doom if every team in the hospital was required to have a pharmacist on rounds and if every patient in retail was required to receive counseling (I mean really get it not sign saying that they got it or don't want it)...So if you agree then why arent you doing something about it? And if you do not agree then please explain your reasoning...sorry for being so long-winded...​

 

[TemSirolimus]

So...recently a professor posed a very interesting series of questions to our class...What would our ideal practice model be? Is that practice model in effect anywhere currently? What are we willing to do about it? You can imagine the variety of answers to the first question but there was an almost unanimous no and nothing to the second two...so here are my two cents and I would appreciate it if you would follow with yours...I have worked in a hospital system (large teaching hospital) for almost two years...I have seen clinical pharmacy in action...I have also rotated through retail...my conclusion? Very few pharmacists are being utilized to their full capacity...I cannot speak for everywhere but I have shadowed at a couple of very progressive, prestigious institutions and although they did more than other facilities, there was still a great deal of room for improvement....so operating under the assumption that generally pharmD's are the experts in drug therapy, is it reasonable to conclude that in an ideal practice model, physicians/pa's/np's would be reponsible for diagnosis and non-pharmacological treatment and pharmd's (residency trained of course) would be reponsible for pharmacological therapy? And on the retail side shouldn't there be more of an MTM approach to each patient? Clearly this isn't the case at very many institutions, so why aren't we fighting for it? Would it not create more jobs and at least eliminate some of the gloom and doom if every team in the hospital was required to have a pharmacist on rounds and if every patient in retail was required to receive counseling (I mean really get it not sign saying that they got it or don't want it)...So if you agree then why arent you doing something about it? And if you do not agree then please explain your reasoning...sorry for being so long-winded...​

On the hospital end of things, diagnosing and prescribing can and will never be mutually exclusive. There is a huge overlap between the two. Great physicians are well versed in drug therapies just as pharmDs.

I am a pharmacy student and I feel that "clinical" pharmacists will never reach their full potential in the interdisciplinary team because they have to rely on other peoples patient assessments.

 

[ChasingMyDreams]

I am not asking for them to be mutually exclusive, only for clincal pharmacists to play a larger role in deciding a course of therapy...why the " " around clinical? And I do not deny that "great" physicians are "well versed" in drug therapy...but how many of those exist? In teaching hospitals residents are writing most of the orders and they are certainly far from "well versed" in anything, let alone pharmacotherapy...And please elaborate what you mean by "other peoples patient assessments"...if a patient is septic and their crcl is 9 what assessment do you have to rely on to decide on and dose the cipro, vanc and zosyn? Similarly, if a patient has uncontrolled htn, type2 dm, etc...the writings on the wall, what assessment are you relying on other than lab values?

 

[spacecowgirl]

I am not asking for them to be mutually exclusive, only for clincal pharmacists to play a larger role in deciding a course of therapy...why the " " around clinical?

Because aside from adjudicating claims, most of what we do is clinical

And please elaborate what you mean by "other peoples patient assessments"...if a patient is septic and their crcl is 9 what assessment do you have to rely on to decide on and dose the cipro, vanc and zosyn?

Oh boy. What is the source of infection? What is the history of the patient? What are the possible pathogens based on the above? What other drugs is the patient on? Oh, I have deja vu. There is so much more than calculating CrCl.

Similarly, if a patient has uncontrolled htn, type2 dm, etc...the writings on the wall, what assessment are you relying on other than lab values?

Ummmm, their QoL, functional status, goals, financial situation, social support, insurance coverage, health literacy, cultural considerations...so much more than lab values. If it were about that, a computer could do anyone's job.

 

[bananaface]

eh...

 

[Pharmavixen]

Ideal practice model: physicians do everything pharmacists tell them.

 

[bacillus1]

I think the problem, at least in retail, is if we ask for more autonomy, they might just give us more autonomy, piled on top of all we do already. We asked for immunizations, we got immunizations. Now there are flu shot quotas in the winter. Now people are resistant to change because if the chains can do MTM, they'll pile on MTM as well if it's profitable for them, without hiring new pharmacists. Most pharmacists work in retail chains, so therefore the apathy.

What needs to be done before changing the pharmacy practice models in chains is to pave the path to allow for enough time/resources for such models to exist. I have spoken to my state pharmacy organization, and they don't want to touch this (my guess is chains and NACDS help them out a lot in the policies they lobby for, including financially). Only way it'll happen is some huge mega-errors followed by immense lawsuits.

 

[ChasingMyDreams]

Because aside from adjudicating claims, most of what we do is clinical

On the hospital side? I beg to differ...If you wanna call verifying orders clinical...idk...i know that there are some pharmacists who are "clinical" in their approach to putting them in but a good bit just type what the order says and if an interaction pops up they handle it...

Oh boy. What is the source of infection? What is the history of the patient? What are the possible pathogens based on the above? What other drugs is the patient on? Oh, I have deja vu. There is so much more than calculating CrCl.

I think you missed the point here...TemSirolimus attemepted to make the point that we must rely on anothers assessment to decide on and dose drugs...you have done nothing but help me prove the point that we do not...source of infection: will probably be obvious...possible pathogens? these will grow out on a culture and the lab results will be in the chart...history of the patient? will be in the chart or you could really be proactive and maybe talk to the patient....Please do not try to belittle me...I realize there is much more to treating a patient than calculating the CRCL but the example was a septic patient so tell me what bugs did I miss? And what is your hospitals protocol for sepsis?

Ummmm, their QoL, functional status, goals, financial situation, social support, insurance coverage, health literacy, cultural considerations...so much more than lab values. If it were about that, a computer could do anyone's job.

Ummmm....these are once again things you can get from the patient not things you must rely on someone else for...and not things listed in a diagnosis....this is exactly the reason I believe pharmacists need more involvement in patient care because we are the healthcare professionals best qualified to consider all of these factors when formulating a treatment plan...I agree with the above statement but my question is why arent you pushing to do these things instead of apathetically standing by?

My point was that lab values confirm diagnoses (sometimes) and with a confirmed diagnosis we can then begin investigating to decide on the best treatment plan and I think our training best prepares us for this type of peractice...

And just for fun...we have a sepsis diagnosis and I agree that there are many things to consider but not things you NEED a physician for...so lets see...alternatives to the above therapy...
If the patient is allergic to penicillins we can go with azactam instead of zosyn...
Maybe a norepi drip to maintain the MAP that is if the CVP is above 8 if not we can do a NS bolus to get the CVP above 8 and then do the norepi drip...
Some DVT prophylaxis? How about Lovenox 40mg q24? Unless of course we have some renal impairment or wanna do heparin...
I could go on forever but I will stop here...the point is we are best qualified to treat the patient after a diagnosis is rendered so why not fight to use what you learned? I just feel like there needs to be more of a real interdisciplinary approach to patient care in more hospitals...and more MTM in retail stores (although the majority of my experience lies in hospital).

 

[spacecowgirl]

Listen, I am a residency-trained, practicing hospital pharmacist and an MTM pharmacist. Don't tell me I'm apathetically standing by, when you're a pharmacy student with no actual pharmacist experience, not to mention NO IDEA what I do at my job. Working as an intern or tech does not count as pharmacist experience no matter how much you think you know about the process.

I'll be back later to comment on the rest of your post.

 

[rxlea]

Ummmm....these are once again things you can get from the patient not things you must rely on someone else for...and not things listed in a diagnosis....this is exactly the reason I believe pharmacists need more involvement in patient care because we are the healthcare professionals best qualified to consider all of these factors when formulating a treatment plan...I agree with the above statement but my question is why arent you pushing to do these things instead of apathetically standing by?

My point was that lab values confirm diagnoses (sometimes) and with a confirmed diagnosis we can then begin investigating to decide on the best treatment plan and I think our training best prepares us for this type of peractice...

And just for fun...we have a sepsis diagnosis and I agree that there are many things to consider but not things you NEED a physician for...so lets see...alternatives to the above therapy...
If the patient is allergic to penicillins we can go with azactam instead of zosyn...
Maybe a norepi drip to maintain the MAP that is if the CVP is above 8 if not we can do a NS bolus to get the CVP above 8 and then do the norepi drip...
Some DVT prophylaxis? How about Lovenox 40mg q24? Unless of course we have some renal impairment or wanna do heparin...
I could go on forever but I will stop here...the point is we are best qualified to treat the patient after a diagnosis is rendered so why not fight to use what you learned? I just feel like there needs to be more of a real interdisciplinary approach to patient care in more hospitals...and more MTM in retail stores (although the majority of my experience lies in hospital).

Some of what you are saying is absurd. Your few hours of shadowing and limited experience cannot possibly give you actual insight into what a pharmacist may/may not be doing. I work at a "progressive, prestigious institution" (as you put it) and the interdisciplinary approach you speak of is part of the workflow. We are not trained for diagnosis nor are we trained to find zebras. Verifying orders is pretty damn clinical, IMO... pharmacists catch things all the time, dose things all the time, make recommendations, etc. Physicians diagnose and prescribe and we are their safety net. Who would be our safety net in your model of care?

EDIT: There ARE pharmacists who prescribe within a limited scope of practice. A few of our preceptors do it at community clinics. But, as I said, they aren't trained to find zebras.

 

[ChasingMyDreams]

Listen, I am a residency-trained, practicing hospital pharmacist and an MTM pharmacist. Don't tell me I'm apathetically standing by, when you're a pharmacy student with no actual pharmacist experience, not to mention NO IDEA what I do at my job. Working as an intern or tech does not count as pharmacist experience no matter how much you think you know about the process.

I'll be back later to comment on the rest of your post.

It was not a shot at you specifically, I was using the 3rd person you as in those in the profession that ARE apathetically standing by...if you are not in that category then I admire you for what you do as I myself aspire to be like you...I mean no disrespect...

 

[ChasingMyDreams]

Some of what you are saying is absurd. Your few hours of shadowing cannot possibly give you actual insight into what a pharmacist may/may not be doing. I work at a "progressive, prestigious institution" (as you put it) and the interdisciplinary approach you speak of is part of the workflow. We are not trained for diagnosis nor are we trained to find zebras. Verifying orders is pretty damn clinical, IMO... pharmacists catch things all the time, dose things all the time, make recommendations, etc. Physicians diagnose and prescribe and we are their safety net. Who would be our safety net in your model of care?

What am I saying that is absurd? Few hours of shadowing? Please dont assume...I have been working (40-50hrs/week) for two years in a "progressive, prestigious institution" as well as picking up hours at other smaller facilities owned by the same hospital system...so I value my experience and I believe it qualifies me to make the statements I have made...I am not saying that the interdisciplinary approach is nonexistent...I am saying that it needs to be more widespread and not just at the "progressive, prestigious institution"....I never said we are trained for diagnosis...I said given a diagnosis we are trained to develop the best pharmacotherapy treatment...geez...do you guys read what I write? And zebras? Verifying orders can be clinical (I said that) but not all pharmacists take this approach...the practice model would still include staff pharmacists as the safety net and clinical pharmacists on the floor, and I am not suggesting pharmacists do all of pharmacotherapy just that they have a much heavier hand in the process...Kudos to all of the institutions that already have this in place, I am aware that they exist (Mayo, UCSF, UCSD, etc.) but I want this model to be in place at the Wherever General's and the So and So's Baptist as well...

 

[rxlea]

What am I saying that is absurd? Few hours of shadowing? Please dont assume...I have been working (40-50hrs/week) for two years in a "progressive, prestigious institution" as well as picking up hours at other smaller facilities owned by the same hospital system...so I value my experience and I believe it qualifies me to make the statements I have made...I am not saying that the interdisciplinary approach is nonexistent...I am saying that it needs to be more widespread and not just at the "progressive, prestigious institution"....I never said we are trained for diagnosis...I said given a diagnosis we are trained to develop the best pharmacotherapy treatment...geez...do you guys read what I write? And zebras? Verifying orders can be clinical (I said that) but not all pharmacists take this approach...the practice model would still include staff pharmacists as the safety net and clinical pharmacists on the floor, and I am not suggesting pharmacists do all of pharmacotherapy just that they have a much heavier hand in the process...Kudos to all of the institutions that already have this in place, I am aware that they exist (Mayo, UCSF, UCSD, etc.) but I want this model to be in place at the Wherever General's and the So and So's Baptist as well...

Maybe I am missing your point here.... what do you mean "heavy hand"? And are you saying that we should push for legislation (as nurses are) to be able to prescribe and do more MTM services? Pharmacists already help develop a pharmacotherapy treatment in hospital settings... so can you clarify/be more specific?

The part I find absurd is making clinical (prescribing) judgements based on the lab values alone- without seeing the patient. I also find it absurd that you think doctors don't know about pharmacotherapy- at least that is what you seem to be conveying. Are there some that suck at it? Yes. But there are some pharmacists I wouldn't trust to fill my own prescription, too.

The "writing is [not always] on the wall"...

I am not trying to sound like a bitch but maybe it comes off that way online...

I just would like to hear more specifics about your model of care based on lab values alone?

 

[Praziquantel86]

Ummmm....these are once again things you can get from the patient not things you must rely on someone else for...and not things listed in a diagnosis....this is exactly the reason I believe pharmacists need more involvement in patient care because we are the healthcare professionals best qualified to consider all of these factors when formulating a treatment plan...I agree with the above statement but my question is why arent you pushing to do these things instead of apathetically standing by?

My point was that lab values confirm diagnoses (sometimes) and with a confirmed diagnosis we can then begin investigating to decide on the best treatment plan and I think our training best prepares us for this type of peractice...

And just for fun...we have a sepsis diagnosis and I agree that there are many things to consider but not things you NEED a physician for...so lets see...alternatives to the above therapy...
If the patient is allergic to penicillins we can go with azactam instead of zosyn...
Maybe a norepi drip to maintain the MAP that is if the CVP is above 8 if not we can do a NS bolus to get the CVP above 8 and then do the norepi drip...
Some DVT prophylaxis? How about Lovenox 40mg q24? Unless of course we have some renal impairment or wanna do heparin...
I could go on forever but I will stop here...the point is we are best qualified to treat the patient after a diagnosis is rendered so why not fight to use what you learned? I just feel like there needs to be more of a real interdisciplinary approach to patient care in more hospitals...and more MTM in retail stores (although the majority of my experience lies in hospital).

You think that anything you mentioned is difficult? Any medical intern will figure all of that out after a month in the MICU. Do you think that a pharmacist can order pip/tazo any better than a physician? You also realize that most of that information you mentioned is protocol driven per JCAHO guidelines, correct?

It's obvious that you have no real perception of what it is that a clinical pharmacist actually does, or what an "interdisciplinary team" is. A pharmacist benefits the team by engaging in meaningful discussion and education with the attendings, residents, and interns as it pertains to drug therapy. Sometimes this is giving an order verbatim or adjusting an existing regimen, other times it may be an impromptu topic discussion about drug use in that particular case.

The true benefit of a clinical pharmacist comes through the implementation of institution-wide drug protocols, education efforts, antimicrobial stewardship and distributive functions. The rounding portion is a relatively minor function, and isn't really what makes a pharmacist valuable to the healthcare system. Yet, you overlook these incredibly important and valuable functions and hope for some pipe dream that isn't really practical, worthwhile or even necessary.

 

[ChasingMyDreams]

Maybe I am missing your point here.... what do you mean "heavy hand"? And are you saying that we should push for legislation (as nurses are) to be able to prescribe and do more MTM services? Pharmacists already help develop a pharmacotherapy treatment in hospital settings... so can you clarify/be more specific?

The part I find absurd is making clinical (prescribing) judgements based on the lab values alone- without seeing the patient. I also find it absurd that you think doctors don't know about pharmacotherapy- at least that is what you seem to be conveying. Are there some that suck at it? Yes. But there are some pharmacists I wouldn't trust to fill my own prescription, too.

The "writing is [not always] on the wall"...

I am not trying to sound like a bitch but maybe it comes off that way online...

I just would like to hear more specifics about your model of care based on lab values alone?

Yea...you are missing my point...but I think its my fault for not being 100% clear....so let me clarify..
Push for legislation for pharmacists to prescribe? Absolutely not. Only those who can diagnose should be able to prescribe. Period. I do think the collaborative practice model that is in place at some institutions is great though...
Push for more MTM? Absolutely. This service is wonderful and I think there should be much more of it...
Clinical judgements without seeing the patient (lab values alone)? Absolutely not. (I will clarify this later)
Physicians dont know anything about pharmacotherapy?
Physicians know a helluva lot about pharmacotherapy often times more than the pharmacist....Cardiologists usually know a great deal about cardio drugs maybe more than the pharmacist (Even if they have a PGY2 in cardiology🙂) but they may not know antibiotics as well... medical residents usually dont know much WELL (they know a lot though) their 1st year so theres an opportunity to teach them pharmacotherapy, making them better physicians...
And I agree that there are good and bad pharmacists and physicians and nurses and...well you get the point...
So ideal practice model? Here goes...
Itll be easier to present in scenario form...
Setting: Internal medicine morning rounds (teaching facility)
Characters: Attending Physician, Attending Pharmacist (my term but same as preceptor/residency trained pharmacist), medical residents, pharmacy residents, med students, pharm students, social worker, case manager, etc...
Then medical resident presents the patient, Chief complaint, HPI, PMH, Labs, vitals, etc and suggests a diagnosis, discussion takes place between medical people, attending confirms diagnosis....then asks pharm students/residents..."how would you treat this patient (if pharmacotherapy is necessary)" attending pharmacists confirms (teaches) treatment plan and asks what physicians think about it...discussion ensues and treatment decisions are made final by both physician and pharmacist...later orders are written (or put in CPOE) by resident physician with help from pharmacy resident to ensure accurate dosing, formulary issues, etc...orders are then sent to the staff pharmacist who will verify and call if any problems are seen...
Is this model in place in some hospitals? Yes
Most hospitals? NO
All I am saying is that I want this model to be universal and I think it would lead to more jobs if a clinical pharmacists were required on every service and not just a luxury and I think it would lead to better overall patient care....
I know it isnt feasible to have all of these people at all hospitals but at least have a clinical pharmacist for every service...

 

[ChasingMyDreams]

You think that anything you mentioned is difficult? Any medical intern will figure all of that out after a month in the MICU. Do you think that a pharmacist can order pip/tazo any better than a physician? You also realize that most of that information you mentioned is protocol driven per JCAHO guidelines, correct?

It's obvious that you have no real perception of what it is that a clinical pharmacist actually does, or what an "interdisciplinary team" is. A pharmacist benefits the team by engaging in meaningful discussion and education with the attendings, residents, and interns as it pertains to drug therapy. Sometimes this is giving an order verbatim or adjusting an existing regimen, other times it may be an impromptu topic discussion about drug use in that particular case.

The true benefit of a clinical pharmacist comes through the implementation of institution-wide drug protocols, education efforts, antimicrobial stewardship and distributive functions. The rounding portion is a relatively minor function, and isn't really what makes a pharmacist valuable to the healthcare system. Yet, you overlook these incredibly important and valuable functions and hope for some pipe dream that isn't really practical, worthwhile or even necessary.

See above post...
And I do recognize the importance of "the implementation of institution-wide drug protocols, education efforts, antimicrobial stewardship and distributive functions", but this is lacking at many facilities...I think we are all arguing the same point....I agree with what you think the "true benefit of a clinical pharmacist" is, I just think there should be more of it....

 

[Praziquantel86]

See above post...
And I do recognize the importance of "the implementation of institution-wide drug protocols, education efforts, antimicrobial stewardship and distributive functions", but this is lacking at many facilities...I think we are all arguing the same point....I agree with what you think the "true benefit of a clinical pharmacist" is, I just think there should be more of it....

On the basis of your prior post, I don't think we're arguing the same point. Yes, optimally there would be a pharmacist rounding on every service, and I hope that happens one day. However, the functions I mentioned are indeed present at many, if not most, institutions and have substantial room for improvement. I think that should be taken care of prior to "chasing the dream" so to speak.

If you look at the institutions that do have pharmacists present, they tend to be the large, academic institutions. Part of the reason for this is the presence of a pharmacy school - the school provides the manpower. Other institutions are well-funded enough where they can justify pharmacists in the "high-risk" areas, such as critical care units, transplantation and antimicrobial stewardship. The smaller community institutions do not have this ability, and it's therefore rare to see a "clipboard pharmacist". It's hard to justify a $120,000 salary for someone who is unable to bill for their services and talks to physicians all day.

Some hospitals get around this by utilizing a hybrid model, which is truly the direction where pharmacy is going. Round in the morning, verify/distribute in the afternoon. One or two clinical coordinators oversee this process, and people seem to be genuinely happy with it. That's the model we should be aiming for.

 

[ChasingMyDreams]

Also to Praziquantel86 and rxlea, I have read some of your posts from other topics and I greatly respect your clinical knowledge and I think you guys are great...but please do not insult my intelligence....Praziquantel86, I think I have a firm grasp of what a clinical pharmacist is and does in a variety of practice settings....
I agree with much of what youre saying, I just wish you guys werent so hostile towards me...I am just a P2 trying to get opinions of others on the profession and maybe encourage those who are apathetic (not you guys) to do more to advance the profession...

 

[ChasingMyDreams]

On the basis of your prior post, I don't think we're arguing the same point. Yes, optimally there would be a pharmacist rounding on every service, and I hope that happens one day. However, the functions I mentioned are indeed present at many, if not most, institutions and have substantial room for improvement. I think that should be taken care of prior to "chasing the dream" so to speak.

If you look at the institutions that do have pharmacists present, they tend to be the large, academic institutions. Part of the reason for this is the presence of a pharmacy school - the school provides the manpower. Other institutions are well-funded enough where they can justify pharmacists in the "high-risk" areas, such as critical care units, transplantation and antimicrobial stewardship. The smaller community institutions do not have this ability, and it's therefore rare to see a "clipboard pharmacist". It's hard to justify a $120,000 salary for someone who is unable to bill for their services and talks to physicians all day.

Some hospitals get around this by utilizing a hybrid model, which is truly the direction where pharmacy is going. Round in the morning, verify/distribute in the afternoon. One or two clinical coordinators oversee this process, and people seem to be genuinely happy with it. That's the model we should be aiming for.

I think that "many" or "most" is a stretch...It would be interesting to look at the statistics on that...but my experience is limited and i will speak from it rather than assume...I work for a large, reputable, fairly progressive hospital with a pharmacy school presence in the city...The is one large teaching hospital (800 beds) and the system owns 3 other smaller hospitals in the city which have ~300 beds each...The 800 bed facility is outstanding and has all of the "functions" you refer to but the smaller hospitals have none....Are these patients not as sick? Do they not deserve the same quality of care?
I understand the cost problem and hospitals not wanting to shell out 100K for a clinical pharmacist...however I had a discussion with one of my best friends who is a residency trained transplant clinical pharmacist (one source of my info that helps me formulate the opinions I have) and he saved his hospital 3X his salary with his interventions...so they can afford him...and another one of him....What are your thoughts on that situation?

 

[rxlea]

Also to Praziquantel86 and rxlea, I have read some of your posts from other topics and I greatly respect your clinical knowledge and I think you guys are great...but please do not insult my intelligence....Praziquantel86, I think I have a firm grasp of what a clinical pharmacist is and does in a variety of practice settings....
I agree with much of what youre saying, I just wish you guys werent so hostile towards me...I am just a P2 trying to get opinions of others on the profession and maybe encourage those who are apathetic (not you guys) to do more to advance the profession...

Nobody is insulting your intelligence nor being hostile toward you....

 

[Old Timer]

Yea...you are missing my point...but I think its my fault for not being 100% clear....so let me clarify..
Push for legislation for pharmacists to prescribe? Absolutely not. Only those who can diagnose should be able to prescribe. Period.

You are clearly not experienced enough. Just about every MTM study with diabetics covered by a pharmacist or CRNP following the protocol laid out only showed results with the authority to prescribe.

Your ideas are not fully thought out.

 

[ChasingMyDreams]

OldTimer,
"I do think the collaborative practice model that is in place at some institutions is great though..."
Did you not read the next sentence? Collaborative practice allows pharmacists to pescribe certain drugs within a defined scope, I do not have any problems with this. I do have a problem with pharmacists being able to prescribe any drug to any patient at any time; this is what prescriptive authority for all pharmacists would mean...
Instead of trying to deconstruct my argument, can someone say something constructive???

 

[spacecowgirl]

Instead of trying to deconstruct my argument, can someone say something constructive???

It would really help if you didn't have walls of text but used paragraphs. Most of your posts are too long and jumbled to read. That's my first item of constructive criticism for you. If you want to be understood, be clear in every aspect.

Ok, the dream team you propose:

Go here, Table C1. So in the US, 85% of hospitals have <300 beds; 53% have <100 beds. I'm in a 25-49 bed institution. What you are proposing is not feasible in but the very biggest of hospitals. Like Praziquantel86 said, it's about what realistic monetarily and with amount of work. We very much have an unwritten hybrid model at our hospital and it works very well for us. As CPOE has allowed us to become more efficient, we have taken on a lot of clinical duties that include everything you are talking about. We don't have a cardiology service or ID service although we have those patients at our hospital. We have generalist physicians and therefore generalist pharmacists. We are very busy, but not busy enough to be just verifying orders or just clinical (whatever that means).

I make recommendations all.the.time. about therapy changes in the hospital. Most often they are taken. Sometimes, I'm totally p0wned by the MD because I didn't take into account something that they spent at least 10 years in school to learn. And I'm totally ok with that. But what you see at this huge hospitals is not feasible in most places. Hell, there are lots of hospitals around here that don't even HAVE pharmacists until the local community RPh can come in after closing up his/her shop.

I don't fault you for having an ideal in mind, that's great, you have pep. But you can see a lot of us have been around SDN for a long time and some of us in our careers for a long time. You need to be more appreciative of those of us with experience and certainly you need to be less defensive.

BTW - handling drug interaction warnings can be very clinical. They have been the source of much debate among the RPhs in our dept.

 

[Praziquantel86]

OldTimer,
"I do think the collaborative practice model that is in place at some institutions is great though..."
Did you not read the next sentence? Collaborative practice allows pharmacists to pescribe certain drugs within a defined scope, I do not have any problems with this. I do have a problem with pharmacists being able to prescribe any drug to any patient at any time; this is what prescriptive authority for all pharmacists would mean...
Instead of trying to deconstruct my argument, can someone say something constructive???

This is how this sort of discourse works. We clearly disagree with some of your statements, it's your job to flesh out a rebuttal. This is an excellent topic for discussion, but it isn't a discussion if everyone agrees with you.

Try to convince us that you're right, and we'll do the same.

 

[spacecowgirl]

I saved our facility almost 200K last year with just one small change; I got a pat on the back and a "now we'll be less hurting for money" affirmation. Everyone should be saving their institution money in every possible way. It's how you fight shrinking reimburesment, bad debt, etc., not how you justify having more staff.

 

[Old Timer]

OldTimer,
"I do think the collaborative practice model that is in place at some institutions is great though..."
Did you not read the next sentence? Collaborative practice allows pharmacists to pescribe certain drugs within a defined scope, I do not have any problems with this. I do have a problem with pharmacists being able to prescribe any drug to any patient at any time; this is what prescriptive authority for all pharmacists would mean...
Instead of trying to deconstruct my argument, can someone say something constructive???

You made a simple declarative statement that is demonstrably false. That the rest of your post requires that you pat yourself on the back is of little consequence.

Again, you make simple declarative statements like:

I do have a problem with pharmacists being able to prescribe any drug to any patient at any time; this is what prescriptive authority for all pharmacists would mean...

Not even physicians have unlimited prescriptive authority. I have a license to give injections in Pennsylvania. It is not unlimited. I must follow a protocol with my collaborating physician and I can't immunize anyone under 18. Who said that prescriptive authority would be ipso facto unlimited.

Your arguments are either poorly thought out, poorly worded or possibly both.

 

[Ackj]

I have a license to give injections in Pennsylvania. It is not unlimited. I must follow a protocol with my collaborating physician

I was wondering about this, actually. So this physician who signs off on the protocol, is this something where you actually know him, and the two of you went over this protocol? Is he in any way responsible for what happens to these patients? Or is it just kind of a formality, and CVS gets MD approval at a regional level and just hands out the protocols that have been signed?

 

[Praziquantel86]

I was wondering about this, actually. So this physician who signs off on the protocol, is this something where you actually know him, and the two of you went over this protocol? Is he in any way responsible for what happens to these patients? Or is it just kind of a formality, and CVS gets MD approval at a regional level and just hands out the protocols that have been signed?

In New York, the county medical director or similar person typically signs off so that a group of pharmacists (PAWNY, Rite-Aid, URMC, etc.) in an organization may provide immunizations pursuant to a non-patient specific order. An individual physician may also permit an individual pharmacist or group of pharmacists to immunize one or all of his/her patients. This is incredibly ass-backwards, and not the way it is in the majority of the country.

PSSNY is working on legislation that would allow the medical director of the NYS DOH to provide certified immunizing pharmacists with blanket ability to immunize all citizens of New York State. This has been an ongoing issue, and there are actually several counties in New York where the medical director has refused to sign off on immunizing privileges for pharmacists (I believe Wyoming county, but it may be Cattaraugus) and created quite a to-do.