MD's prescribing

[ribbit541]

this might upset people, but my question is hard to search, i tried...
What relevant information do pharmacists know that MD's dont? the MD's diagnose then pick the correct drug for the job (the MD chooses all 300 drugs that come through my walgreens), and in walgreens there is about a 1% error rate (they never pick the wrong drug), like walgreens pharmacists just double checks the MD's choice. Is it just that pharmacists know MOA's? Interactions (but MD's have to know that too, more so because they actually put together the drug regime that is rarely wrong and littered with interactions)...Do the MD's just look at a big book and go through tables with indication correlating with the correct drug needed (so essentially they dont know but just have a big reference? like I said dont let this upset anyone, I am going to pharmacy school so this isnt some form of physician arrogance.

 

[English102FTW]

Like you said, the pharmacist is there to double check that it's the correct drug to be used, but also to insure that the person getting the medication know what sort of things to expect when taking the drug. It's also important that the pharmacist explains how to take the drug ( sometimes the doctors don't ) and also to make sure the correct dosage is being used. Hope that helps, I'm not a pharmacy student but I'm pretty sure what I stated is true.

 

[Aznfarmerboi]

For one thing regarding your setting, you have different prescribers. You might have a dentist prescribing antibiotics and pain killer while another MD prescribing warfarin.

In my experience, hospital doctors (ie attendings) will probably know more about drugs than retail pharmacists do as they have access to literature that we dont. However private practice prescribers might not be up to date because they are busy and that is where you *might* shine.

All in all, a retail pharmacist is there to watch out for CII's, OTC recommendation, counseling patients on medications (required by law), ensuring accuracy (1 percent rate is way too low. I would put that number at about 3-4 percent, accuracy is about transcription, dosage, frequency, correct number, right drug, etc), recommendation to doctors, and managing the pharmacy itself in terms of inventory, staff, etc (consider a practice of pharmacy).

MDs prescribe based on which hospitals they did their training on. For the most part, they know about the pharmcotherapy of classes of drugs but I highly doubt that they know the difference between this statin versus another statin unless it is important (as in short acting versus long acting hypertensive medications). The rest of their pescribing habits is based on their experience of what works and dont, drug reps, and the journals they subscribed to. They do not have a big book, but they do have a computer with programs like we do to help them pick the treatment.

 

[CanPharm]

I've kinda wondered about that before also. But, I think the physicians will only use the drugs that they are used to, or the drugs that they saw other doc's use during their residencies. For the most part, a specific physician will not use all 300+ drugs. A cardiologist will only use cardiovascular related drugs, and will probably have forgotten most of the psychiatric drugs. A family physician will have their favorite for each chronic condition, or whatever the rep says is better hehe. And even so, they may sometime not get it right.
For example, I recently went to a physician's office to shadow as part of my community pharmacy rotation. A patient came in with an unresolved UTI. She was already on nitrofurantoin, and had a sulfa allergy. So the doctor wanted to try something else. So, he asked me which one I would choose (to test me). I told him he could use a fluoroquinolone, such as ciprofloxacin. Surprisingly, he said levofloxacin would be a better choice because it has "better coverage." I didn't challenge him, but the funny thing was that he went back to the CPS (a compilation of drug monographs in Canada) to double check his answer after the patient left. Obviously, the monograph would say it could be used for UTI's (because the manufacturers want to sell their product), but as we know, it is not a good choice because it has an increased efficacy for respiratory organisms, but not for urinary tract infections, and this also increases drug resistance.
But long story short, Dr's also need to check the book if they are not sure. And even if they pick a possible drug, it may not be the best one. Also, any one physician does not know about all the drugs available. They probably have a first and second choice, possible a third. As a pharmacist you need to know all about the medications you have on your shelf. This include drug interactions, expected time of efficacy, drug-medical condition interactions, cross-sensitivities, side effects, storage properties, etc.

 

[njac]

I haven't worked any retail. but I know that in the hospital I call MDs quite a bit about what they've written for. That may be because I'm in a teaching hospital and we have many residents - but on occasion I'm calling attendings, too.

Do you really want that Fluconazole BID?
Ceftriaxone 2g Q12H for SBP?
ESRD kid with a K of 3 over 14 hours ago (pre-op) - do you want her maintenance fluids to be D51/2NS with 20K @ 100cc/hr with no labs ordered?
25 mg Vitamin K for an INR of 3.6 and no active bleed?

That's just what I can recall off the top of my head from a 6 hour shift last night. Not all of those are lifesaving (we could've let the Ceftriaxone go, it probably wouldn't hurt the pt) interventions but I think it's worth it to let people know about their mistakes. I certainly want to hear about mine.

 

[ribbit541]

With regards to the hospital, I have shadowed a few times and yes, pharmacist do make many more "suggestions" and fixes, its actually a very good environment at the hospital I was in, I want to end up at a hospital after grad. But another way to phrase my question, do you think a family doctor could work as a pharmacist at walgreens?

 

[RxWildcat]

do you think a family doctor could work as a pharmacist at walgreens?

no?

 

[PharmDstudent]

no?

maybe an NP (alongside the pharmacist in a pharmacy and ambulatory-type doc-in-the-box combo)

 

[Trancelucent1]

As for MD's choosing a drug, sometimes it just comes down to which drug rep was in their office recently. I could write a really long response regarding correct selection/dose but I don't feel like it right now.

 

[Monkeyguts]

I've kinda wondered about that before also. But, I think the physicians will only use the drugs that they are used to, or the drugs that they saw other doc's use during their residencies. For the most part, a specific physician will not use all 300+ drugs. A cardiologist will only use cardiovascular related drugs, and will probably have forgotten most of the psychiatric drugs. A family physician will have their favorite for each chronic condition, or whatever the rep says is better hehe. And even so, they may sometime not get it right.
For example, I recently went to a physician's office to shadow as part of my community pharmacy rotation. A patient came in with an unresolved UTI. She was already on nitrofurantoin, and had a sulfa allergy. So the doctor wanted to try something else. So, he asked me which one I would choose (to test me). I told him he could use a fluoroquinolone, such as ciprofloxacin. Surprisingly, he said levofloxacin would be a better choice because it has "better coverage." I didn't challenge him, but the funny thing was that he went back to the CPS (a compilation of drug monographs in Canada) to double check his answer after the patient left. Obviously, the monograph would say it could be used for UTI's (because the manufacturers want to sell their product), but as we know, it is not a good choice because it has an increased efficacy for respiratory organisms, but not for urinary tract infections, and this also increases drug resistance.
But long story short, Dr's also need to check the book if they are not sure. And even if they pick a possible drug, it may not be the best one. Also, any one physician does not know about all the drugs available. They probably have a first and second choice, possible a third. As a pharmacist you need to know all about the medications you have on your shelf. This include drug interactions, expected time of efficacy, drug-medical condition interactions, cross-sensitivities, side effects, storage properties, etc.

Levofloxacin is a suitable choice for UTI's and has good coverage to both urinary and respiratory pathogens. In my part of the country resistance to cipro by e. coli approaches 30%.

And levofloxacin is a fluoroquinolone just as cipro is. I would agree with you if you were talking about moxi as this does not reach adequate levels in the urine, but levofloxacin is a different story.

 

[CanPharm]

Levofloxacin is a suitable choice for UTI's and has good coverage to both urinary and respiratory pathogens. In my part of the country resistance to cipro by e. coli approaches 30%.

And levofloxacin is a fluoroquinolone just as cipro is. I would agree with you if you were talking about moxi as this does not reach adequate levels in the urine, but levofloxacin is a different story.

Thats cool. Our resistance patterns are probably different than you guys, I suppose you are from the US. But in my province, based on our resistance trends, the only fluoroquinolone that should be used for UTI are norfloxacin and ciprofloxacin. They should definitely be be used even before considering levofloxacin. Levofloxacin is still considered to be big gun (although we are using higher doses now) for pneumonia and we would definitely want to preserve it if possible. But yeah, the story I described would probably be more effective if you were from where I am. But the main point was to say that sometimes MD's may not choose the most effective drugs.

 

[Requiem]

Thats cool. Our resistance patterns are probably different than you guys, I suppose you are from the US. But in my province, based on our resistance trends, the only fluoroquinolone that should be used for UTI are norfloxacin and ciprofloxacin. They should definitely be be used even before considering levofloxacin. Levofloxacin is still considered to be big gun (although we are using higher doses now) for pneumonia and we would definitely want to preserve it if possible. But yeah, the story I described would probably be more effective if you were from where I am. But the main point was to say that sometimes MD's may not choose the most effective drugs.

America has way worse resistance patterns of almost every bug compared to Canada.... our ID prof did a presentation in the states on cefazolin for Staph Aureus... tons of Americans were baffled that you could actually use that and it worked - everything there is vanc as it's all private $$