MDs Aruge Pharmacists Shouldn't Prescribe: A Cross-Disciplinary Thread

[qwopty99]

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Hi folks

I'm going to point to a thread in the optometry forums that I started. I know SDN doesn't permit posting threads in multiple forums - but due to its cross-disciplinary nature, I think it's appropriate for me to draw attention to it.

Absolutely Ridiculous Argument for an MD to Make Against Pharmacists
http://forums.studentdoctor.net/showthread.php?p=7399530#post7399530

It discusses an article published in the Toronto Star (the most widely circulated newspaper in Canada) on the MD argument as to why pharmacists shouldn't be given the right to "prescribe". As an OD, I can make "educated" commentary on the MD's argument in the article - and I can assure you, it's seethingly ridiculous.

If any of you folks can get involved in that discussion (e.g. can someone tell me how to post a comment to that newspaper site?), it's worth bringing up the logical fallacy that I brought up.

 

[psurocks]

i agree, i dont have the training to prescribe, MD go thru 4 yrs of school, + min of 3 yrs training, a lot more than we do....we just dont have the background to dx a disease

i do feel comfortable doing, and the mds dont care, is switching drug for tx depending on insurance copay (coverage) on that drug

 

[WVUPharm2007]

Us diagnosing is the dumbest idea I've seen in a while. It's something I specifically don't want to do, anyway. I've never given a rectal exam to an obese man that hasn't showered in 25 days. I'd like to keep it that way.

Now I *might* picture a situation where, upon being given a diagnosis, I would be expected to make choices about drug therapy. If there's one thing I've learned in my short career, it's that the average physician knows diddly about the optimal use of drugs.

 

[psurocks]

Us diagnosing is the dumbest idea I've seen in a while. It's something I specifically don't want to do, anyway. I've never given a rectal exam to an obese man that hasn't showered in 25 days. I'd like to keep it that way.

Now I *might* picture a situation where, upon being given a diagnosis, I would be expected to make choices about drug therapy. If there's one thing I've learned in my short career, it's that the average physicians knows diddly about the optimal use of drugs.

EXACTLY...whenever i call a MD about a DNC, he/she expects me to tell him/her alternatives...ie I'll be like: hey doc, this levaquin isnt covered, what are you treating this pt for? if its like CAP, i'll make the suggestions, if its for UTI, i'll make suggestions

or, say skelaxin is non preferred product on pt insurance, i call md to change, i will tell him what he/she can go with

etc

 

[medicalCPA]

Here we go again...

 

[Quiksilver]

here is something to chew on though, both NPs and PAs both get maybe 2 semesters in pharmcology and they can prescribe anything under the sun. They have less experience and knowledge with drugs then anyone else, yet they can prescribe. And I have heard stories about their diagnostic skills, and they may are not on par with a doctors skill either, and yet they have the autonomy to make a diangosis without consulting a physician. I am not advocating my profession to be able to prescribe, but how do you justify them prescribing? I think we should have a little more freedom then being a trained monkey that only fills what the doctor says.


What i think pharmacists should do is if given a prescription for something (implying that a diagnosis has been made) that we may modify it within a set of guidelines. For example Mrs. Smith comes in with a script for Nexium, and oh no its not covered. Its now a saturday, doc won't be in. Let me be able to change it to Prilosec without going through the hassle of calling the doctor and wasting both of our time. or ACE-I being switched with an ARB. Stuff like that. Another fantastic thing would be if we can approve refills of Rxs for a given amount of time say for 14 days so that the patient has enough time to get a new rx to continue therapy.

 

[VCU2011]

I've never worked in a hospital so i dont know for sure, but what I hear is that the physicians many times will just write the class of drug on a script and the pharmacist has the discretion to fill it for whatever in that class. Granted that probably doesn't make much difference due to formularies, but i think it would be fine if the pharmacist worked with the patient to figure out the best drug in a class for the patients.

For example if a pt was just diagnosed with diabetes and they physician wants them on a sulfonylurea, just let the pharmacist discuss with the patient and choose the best one within the class. This would prevent the overperscribing due to drug reps (as far as physicians are concerned), would make it easier to get things done under the constraints of an insurance company, and make it easier for pharmacists to assess intracacies of the drugs that physicians may not be aware of.

 

[BMBiology]

Most pharmacists don't want to prescribe. That being said, physicians have lost a lot of their political clout. The New York Times is constantly writing stories about physicians and their association with the drug companies. Here's the lastest one:

http://www.nytimes.com/2008/11/22/health/22radio.html?_r=1&ref=health

 

[ItsOverZyvox]

I don't want pharmacist prescribing nor do I want to prescribe. I want the physicians to diagnose and prescribe. Except do so within the parameters set forth by the hospital committees.. ie, the Formulary and prescribing guidelines. Not because a pretty drug rep brought lunch.

How hard is that?

 

[MountainPharmD]

I don't want pharmacist prescribing nor do I want to prescribe. I want the physicians to diagnose and prescribe. Except do so within the parameters set forth by the hospital committees.. ie, the Formulary and prescribing guidelines. Not because a pretty drug rep brought lunch.

How hard is that?

Shut up... Ok, I agree with him. But I just wanted to tell him to shut up..

Back at ya!

 

[UNMorBUST]

I vote for a . Pharmacist perscribing is a conflict of interest.

 

[genesis09]

The fact is pharmacist prescribing is a growing trend. In Canada, a number of pharmacists can prescribe. What I predict, in the coming years despite MDs complaints, is the emergence of the third class of drugs. I think that will be a satisfactory outcome to most involved in this. The important thing is to see what the FDA will do with regards to that proposition. The FDA hasn't done anything since last year because of the election. They know might be willing to make a move.

 

[njac]

In New Mexico we have the pharmacist clinician certification, PhC. I believe it is granted through the board of pharmacy and the board of medical examiners in a combined venture.

The pharmacist has to provide documentation of at least 300 patients and 150 patient contact hours supervised by a physician or mid-level with descriptions of what exams were performed, etc. Then the pharmacist must submit a copy of their intended protocol to a committee - basically algorithms of what disease states they care to treat and how - anticoagulation pharmacists will have one describing adjustments in warfarin dose based on INR, anti hyperlipidemic people address the different medications available and their places in therapy.

Anyway, the provider cannot prescribe outside of this approved protocol. They must practice under a physician or mid-level.

I've "grown up" in a pharmacy community where this is the norm - I've been taught to think this is a good thing. The pharmacists do not diagnose patients, but work with patients on disease maintenance. Lipid management, hypertension management, anticoagulation, smoking cessation. If a patient presents outside of the protocol, the patient is referred to the physician or whoever.

 

[Priapism321]

The pharmacist has to provide documentation of at least 300 patients and 150 patient contact hours supervised by a physician or mid-level with descriptions of what exams were performed, etc.

I will never be supervised or do anything "under" a midlevel. Give me a break.

 

[njac]

I will never be supervised or do anything "under" a midlevel. Give me a break.

I believe they had to put that in to placate the PAs. I agree with you. But for every ***** PA and NP I've met, I've dealt with a fantastic PA and NP. And that doesn't even take into account the ***** physicians out there. At least you establish yourself under a practitioner of your choice, it's not like it's assigned.

 

[Glycerin]

I will never be supervised or do anything "under" a midlevel. Give me a break.

You sure are bursting with enthusiasm today. 😉

 

[Aznfarmerboi]

I dont want to prescribe. I do wish that one day, I can do refill automatically under a set of protocols, order tests that are relevant to drug monitoring, and prescribe after the doctor diagnosis the condition based on protocols (ie army). NYS sucks.

Although I agree that we shouldnt get too far, I think we all agree that as of right now, our practicing rights are too limited for the education that we are given. (We should be able to switch drugs within the same family class, authorize refills for patients who are stablized on medications, etc).

 

[patmcd]

I don't think we should be diagnosing people, but a pharmacist should be more than capable of prescribing meds based on a physician dx. For that matter in many situations a pharmacist maybe better at it....we are supposed to be the drug experts after all right?

 

[meister]

I sort of feel like eventually MDs will provide dx and maybe tx, but in a collaborative way PharmDs may be able to alter tx. I don't think anyone's suggesting that PharmDs should be diagnosing people as of this second, but I don't see why they shouldn't be allowed to alter therapies or something similar, as long as they notify the MD and everyone knows what's going on.

The big problem is that you have a whole generation of BSc RPhs, many of whom are wholly unqualified for such tasks. Now, obviously I'm grossly generalizing, but I think we can all agree that there are many RPhs out there who simply want to check off scripts and use very little discretion. What do you suggest pharmacy do with the non-PharmDs who were never trained to the same level as modern day PharmD graduates?

There's a very big disconnect in the profession right now. And also there is a ton of inertia in the private sector, and MDs do not want to give any more autonomy up than they already have to mid-levels like PAs/NPs with respect to prescribing rights. There is a very good argument currently against letting pharmacists at retail chains, for example, alter therapies or order labs or things like that simply because the US has abysmal electronic medical records and there's a snowball's chance in hell that the MD's office would be able to handle 50 such changes a day from pharmacies.

 

[Priapism321]

Since no one has posted it yet, and the discussion continues, I will throw this out there for the peanut gallery to peruse. Two weeks ago an article was published detailing the process and credentialing in Canada that must be satisfied before a Druggist can "independently" prescribe a drug. The piece provides some insight, and also points out that there is no magic wand being waved that all of the sudden allows any dip**** at Walgreens to pick up a prescription pad and start firing off Rx's for amiodarone.

This is only the abstract of course, and if you are commenting on this thread, you should have some idea about how to access the full text article.

http://www.ajhp.org/cgi/content/abstract/65/22/2126

 

[bigpharmD]

The big problem is that you have a whole generation of BSc RPhs, many of whom are wholly unqualified for such tasks.

One of the best clinical pharmacists I know is a BSpharm. There are many BS pharmacists who I would much rather work with than some of the new grads coming out of school that think they deserve to be an attending physician. I am not sure what the future holds for pharmacist prescribing, but I am not, and never will be a midlevel. If you want to be a midlevel then go to PA or NP school. They are great at writing progress notes and electrolyte boluses.

 

[IamMDMBA]

I've never worked in a hospital so i dont know for sure, but what I hear is that the physicians many times will just write the class of drug on a script and the pharmacist has the discretion to fill it for whatever in that class. Granted that probably doesn't make much difference due to formularies, but i think it would be fine if the pharmacist worked with the patient to figure out the best drug in a class for the patients.

For example if a pt was just diagnosed with diabetes and they physician wants them on a sulfonylurea, just let the pharmacist discuss with the patient and choose the best one within the class. This would prevent the overperscribing due to drug reps (as far as physicians are concerned), would make it easier to get things done under the constraints of an insurance company, and make it easier for pharmacists to assess intracacies of the drugs that physicians may not be aware of.

LOL, where do you people dream up of these things? I can just write "BP med", "little white pill for red eye thingy"??
Let's toy with you for a bit, so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL! And then, since you don't follow the pt, how do you know to adjust the dose?
BTW, I went to MCV, it NEVER happened like you claim....PWNED!

 

[MountainPharmD]

LOL, where do you people dream up of these things? I can just write "BP med", "little white pill for red eye thingy"??
Let's toy with you for a bit, so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL! And then, since you don't follow the pt, how do you know to adjust the dose?
BTW, I went to MCV, it NEVER happened like you claim....PWNED!

I am with you on that one. I can see it now.....prescriptions coming in with nothing on them except blood pressure or antibiotic or cholesterol med. That would be awsome. 👎

 

[BMBiology]

so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL!

You have not never heard of electronic medical records? Protocols? Kaiser? You can pretend to have a MD and MBA but I doubt anyone actually believe you. Don't reply to my post just yet. Calm down and think first.

 

[confettiflyer]

LOL, where do you people dream up of these things? I can just write "BP med", "little white pill for red eye thingy"??
Let's toy with you for a bit, so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL! And then, since you don't follow the pt, how do you know to adjust the dose?
BTW, I went to MCV, it NEVER happened like you claim....PWNED!

hahah well look who came back for more, the little 19 year old pretend doctor/mba/insert degree here! looks like he got yelled at at work again and needed to to jerk off to the pharmacy forum. 😍

 

[dr of rx]

I am with you on that one. I can see it now.....prescriptions coming in with nothing on them except blood pressure or antibiotic or cholesterol med. That would be awsome. 👎

true story..
a customer once brought in an RX from a NP (big surprise) that read

"herpes simplex 5x daily" 🙄


PA's and especially NP's scare me. They have too much prescriptive authority.

 

[njac]

true story..
a customer once brought in an RX from a NP (big surprise) that read

"herpes simplex 5x daily" 🙄


PA's and especially NP's scare me. They have too much prescriptive authority.

for the most part PAs scare me more than NPs.

just sayin.

 

[Pharmacy Kid]

LOL, where do you people dream up of these things? I can just write "BP med", "little white pill for red eye thingy"??
Let's toy with you for a bit, so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL! And then, since you don't follow the pt, how do you know to adjust the dose?
BTW, I went to MCV, it NEVER happened like you claim....PWNED!

http://forums.studentdoctor.net/showthread.php?t=321905
"At my institution, the clinical pharmacist have delegated prescriptive authority, meaning I can write orders and sign them without having to "verbal order". The only drugs I have to get signed by the MD's are C 2's and chemo."

This is definitely the exception rather than the norm, but I just wanted to show you it exists. There's also the VA and IHS. I think it would be nice for a pharmacist to have the option of undergoing training for prescriptive authority if they wanted. If you don't want to write scripts, you don't have to undergo the extra training.

Also, I think it's interesting the PA program at Shenandoah is only 2 years whereas pharmacy school is 4 years. That tells me one of 2 things: the PA program squeezes a lot into 2 years and/or pharmacy school has inefficient courses.

 

[bigpharmD]

Is this why I routinely get these orders in the hospital:

"formulary ace inhibitor--pharmacy to dose"
"PPI of choice--pharmacy to dose"
"mylanta--pharmacy to dose (no joke)"

Where do they dream these things up MDMBA?

 

[meister]

Also, I think it's interesting the PA program at Shenandoah is only 2 years whereas pharmacy school is 4 years. That tells me one of 2 things: the PA program squeezes a lot into 2 years and/or pharmacy school has inefficient courses.

I think that's just PA schools focusing on diagnosis and pharmacy school focusing on drugs. PAs learn "diagnosis -> this treatment" with little elaboration, and tend to focus more on how to arrive at the diagnosis (obviously).

One of the best clinical pharmacists I know is a BSpharm. There are many BS pharmacists who I would much rather work with than some of the new grads coming out of school that think they deserve to be an attending physician. I am not sure what the future holds for pharmacist prescribing, but I am not, and never will be a midlevel. If you want to be a midlevel then go to PA or NP school. They are great at writing progress notes and electrolyte boluses.

Of course a pharmacist isn't a mid-level practitioner, that is not what I said at all. I also noted exceptions by saying that I was grossly generalizing. I was simply stating that there is a big reluctance by MDs to cede any more authority on prescriptions because of how much they already have ceded to mid-levels (NPs/PAs). Current PharmD grads get way more clinical focus than the old BSpharm grads did, wouldn't you agree? You have to consider that when discussing RPh RxP.

 

[Farmercyst]

LOL, where do you people dream up of these things? I can just write "BP med", "little white pill for red eye thingy"??
Let's toy with you for a bit, so I write "sulfonyurea", "diuretic", whatever...how on earth would you know what dose, frequency, whether you failed lasix before? LOL! And then, since you don't follow the pt, how do you know to adjust the dose?
BTW, I went to MCV, it NEVER happened like you claim....PWNED!

More likely to happen in VA, Kaiser setting, but also specialized am care settings. We happen to have a PharmD on faculty who may get a patient referred to by the MD to monitor such patients and make med changes, dose changes, etc without explicit MD approval (protocols technically mean approval, but that's more technical than individually approving every change). Granted since everything is done under protocol which means some level of MD oversight, but since he's been doing it for years and knows what he's doing, the oversight is minimal.
As MTM becomes more prevalent it may occur in other settings, but the referral wouldn't come on an RX is would be a phone call, fax, email etc. And the Pharmacist gets medical records with the referral, so failing lasix would be known. Of course the RPh would also have to contact the other MDs working with the patient to get a complete history as MDs generally don't talk to each other as much as you'd hope.
You can take what I say with a grain of salt as a lowly P2, but the sources are rather reliable on my end. MDs and PharmDs primarily.

 

[Omegadramon]

iirc, Cubicin and another restricted antibiotic has to have clearance with one of our clinical pharmacists and the ID docs.

 

[RNtoPharmD]

here is something to chew on though, both NPs and PAs both get maybe 2 semesters in pharmcology and they can prescribe anything under the sun. They have less experience and knowledge with drugs then anyone else, yet they can prescribe. And I have heard stories about their diagnostic skills, and they may are not on par with a doctors skill either, and yet they have the autonomy to make a diangosis without consulting a physician.

Yep.. they may know less about the drug. But they learn about diagnosis and they have rotation that actually assess the patient at bedside in a "primary" caregiver capacity. I am just a P1 so I could be wrong. We may have health assessment class in pharm school. But do we go at bedside and touch and assess patient from head-to-toe and write orders?.. I don't think so..

Like you, I do not agree with pharmacist making diagnosis unless we change our curriculum and include rotation as a primary care giver. However, I agree that pharmacist should be able to independently adjust dosage and make therapeutic substitution.. and possibly prescribe for minor illness like cold, allergies etc and possibly for moderate pain..

 

[twester]

I don't want pharmacist prescribing nor do I want to prescribe. I want the physicians to diagnose and prescribe. Except do so within the parameters set forth by the hospital committees.. ie, the Formulary and prescribing guidelines. Not because a pretty drug rep brought lunch.

How hard is that?

It's so obvious my doc is under the influence of drug reps. The only time he came out with a generic drug recommendation was for lisinopril.

It goes something like:

Him: I think Glumetza would be a good choice. What do you think?

Me: That's not on my insurance's formulary. How about metformin ER?

Him: Is that generic? Are you sure?

Me: Look it up.

Later on another encounter:

Me: The escitalopram is giving me diarrhea and the shakes.

Him: The what?

Me: The Lexapro

Him: Oh, right, I don't know generic names.

Me: Well, it's not on my formulary either. Can you call in 40mg of citalopram instead?

Him: Citalopram?

Me: Celexa

I swear, if it didn't come with lunch, my doc isn't going to know the drug. He's a good doc, though, even if his drug knowledge is somewhat limited.

 

[okcpharmd]

Him: Citalopram?

Me: Celexa

That's funny. I am an ER Pharmacist and I had the Chief ER Doc ask me the same one. "What is citalopram?"

I also get "what is metoclopramide?", "what is Ranexa?", "Oh, I can't give metformin to the lady with the creatinine of 3", and "I didn't know you can't give Phenergan to a child less than two."

I'm not saying I can diagnose and I don't want to. But I am fully capable of writing orders for pain control, hypertension, nausea, fever, hyperglycemia, electrolyte disorders, etc. Actually, I often write the order, then later tell the physician what I have done. What bothers me is that I have to write it as a verbal order even though I am doing it autonomously. Our dental residents in the hospital can prescribe and know very little about the meds they are giving, especially whether a med interacts with the patient's home meds or not.

Pharmacist prescribing should be clarified as either a Clinical Pharmacist prescribing with full access to medical record and history, or a Retail Pharmacist prescribing PPI's (and such) and changing within a drug class. No sane person would argue that a pharmacist in a retail setting should be able to start a patient on a beta-blocker or diuretic based on a two minute consultation without labs, ekg, etc.

 

[bigpharmD]

You guys need to get over the prescribing thing...I am a consultant about medications...I could care less if i prescribe....I have physicians call me at 8 PM to ask me if what they are doing sounds good or if I would do something else.....They are not calling the PA or NP to ask them if what they are doing is right....I am fine with being a consultant on proper medication use...