Pharmacist Prescribing?

[patmcd]

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How much do they usually make? I hope they have a pretty high salary...

They seem to do pretty well. I think I saw some job listings for specialist pharmcists at a VA hospital for ~105K.

I think patmcd is referring to clinical pharmacists who specialize in oncology. These pharmacists do exist already in institutions such as University of Maryland and Johns Hopkins hospital. The job of these pharmacists includes keeping up with every new chemotherapy trial as well as evaluating new chemotherapy and supportive therapy. They go through 4 years of pharmacy school and 2 years of residency specializing in this field. They give input to oncologists during rounds, verify the chemotherapy orders, give seminars on different aspects of oncology to the staff, help develop institution specific protocols and formularies, and provide patient education.

Thats exactly what I was talking about. Retail or general hospital pharmacists don't really have a need for prescribing rights. But a specialist pharmacist is an expert in their field and I would hope knows just as much about the drug treatment options as a doctor in the same specialty. Sometimes being a specialized clinical pharmacist also means that you help teach doctors doing a residency in your field (ie: oncology, cardiology, etc). If your qualified enough to help teach the doctor, then I'd hope that you could be on the same playing field as them. Getting pharmcists directly involved in choosing the best drug could only help a patient. Two heads are better than one.

 

[ProZackMI]

Has anyone heard of the CPP (Clinical Pharmacist Practitioner)? Apparently, it's an Act in NC that allows PharmDs with specialized post doc training (residency or fellowship) to Rx under MD/DO protocols as well as order labs, perform PEs, etc.

Check out these links:

http://www.ncpharmacists.org/displaycommon.cfm?an=13

http://www.ncbop.org/ch46-31.htm

http://www.ashp.org/gad/monthlyupdates/legislative/July_2004.cfm

http://72.14.203.104/search?q=cache...acist+Practitioner"&hl=en&gl=us&ct=clnk&cd=27

It looks like the CPP is also in practice in NM.

 

[ProZackMI]

Kind of like a Doctor's office? I'm sure most people would rather go to a pharmacy if they have a flu and just have the pharmacist prescribe them a drug instead of going to a doctor to pay them 70 dollars for the Doctor to tell them something they already know...just a thought.

HEHE! Wow, I now have a mouthful of chai tea on my keyboard. Thanks for the laugh, Insipid. How true you are.

 

[ProZackMI]

I don't know, probably the same place they got their leeches and emetics. You don't really advocate a return to 15th century medicine do you?

How about those pharmacists prescribing medications? It's been clearly established that you have no ethical qualms about dispensing medications, so how about pharmacists diagnosing and prescribing? According to Wikipedia, the repertory of all things modern and colloquial , a troll is:

"someone who comes into an established community such as an online discussion forum, and posts inflammatory, rude or offensive messages designed to annoy and antagonize the existing members or disrupt the flow of discussion (see Anonymous Internet posting)."

So, Mr. FamilyMD, whatdya think of pharmacists prescribing medications?

I think FamilyMD has forgotten that back in the day, the physicians doubled as barbers, and were uneducated dabblers in the healing arts, whereas the apothecaries and alchemists were among the few learned folk to obtain a university degree.

 

[patmcd]

Has anyone heard of the CPP (Clinical Pharmacist Practitioner)? Apparently, it's an Act in NC that allows PharmDs with specialized post doc training (residency or fellowship) to Rx under MD/DO protocols as well as order labs, perform PEs, etc.

Check out these links:

http://www.ncpharmacists.org/displaycommon.cfm?an=13

http://www.ncbop.org/ch46-31.htm

http://www.ashp.org/gad/monthlyupdates/legislative/July_2004.cfm

http://72.14.203.104/search?q=cache...acist+Practitioner"&hl=en&gl=us&ct=clnk&cd=27

It looks like the CPP is also in practice in NM.

VA hospitals also offer something similar to this. I wonder if any other states have current laws in the works too?

 

[goodb29]

I actually did a rotation at a VA hospital and the clinical pharmacists there do all of the followup appointments for the physicians at the facility. They can actually prescribe, change doses, order lab tests, perform physical assesment of patients. They also are in entirely in charge of the anti-coag clinic at the hospital. All VA hospitals are set up this way. It is very advanced at the VA and years ago they used to have NP (Nurse Practitioners) do these follow up appointments but they found that patients have better outcomes with a clinical pharmacist. Hopefully other hospitals/clinics and pharmacies will follow their lead

 

[kwizard]

VA hospitals also offer something similar to this. I wonder if any other states have current laws in the works too?

Clinical Pharmacists Practitioners act in NC is basically one the first collaborative practice agreements (this subject has been discussed on various other threads). Obviously the collaborative practice agreement varies from state to state so the autonomy one receives will vary based on state law. Most of which are listed in the most recent position statement by ACCP on Collaborative Drug Therapy Management (http://www.accp.com/position/pos2309.pdf)
Additional info can also be found for generally on http://www.accp.com/position.php
and scroll down to position papers.

While all of these collaborative practice agreements are nice the the biggest hurdle is placing pharmacists in a position to actually apply these agreements. Most pharmacists working in the field are either in retail or hospitals so typically only a few pharmacists in academia have time alotted in their schedule to develop such a unique practice site w/ a physician in private practice (or anywhere in the community for that matter) functioning in a collaborative role (excluding anticoag clinics). Once again the issue is "why bother" unless the pharmacist can bill for service b/c there is no financial benefit that can be seen immediately by the administrator who may have to fiscally justify the position and may be devoid of any insight for long term preventative care. Having said that another alternative for pharmacists practicing more clinically in the community would be the straight common med management approach (i.e. minimizing polypharmacy, minimizing drug expenditures, decreasing hospital admissions, etc.). We all do this method in some shape or form but we collectively as a profession tend to forget to track the data and show the outcomes (i.e. decreased medications, decrease cost to pt, decr. hospital admissions, decr. cost to hospital). A good example of one program that has been quite effective at illustrating potential of pharmacist in this regard (w/ some outcome tracking) would be the REACH/Pharmacist CARE program at UK. Its also an example of an active collaborative practice being applied clinically (http://www.uky.edu/Pharmacy/REACH/ or http://www.mc.uky.edu/pharmacistcare/default.asp).

Many other pharmacy schools have similar templates as well.

Now on to my beloved VA system...VA is great if you can get into a progressive VA as every VA should be judged on an individual basis as each VA pays different and has different opinions of clinical pharmacy. Nonetheless back in mid 90's VA gave prescribing rights to the various mid-level practitioners (NP, PA etc) but also included Clinical Pharmcists in this Directive. I'm not sure if the NP or PA had prescribing privileges before as they have in private sector, but since I'm a pharmacist that is my focus. Nonetheless the VA granted a Clinical Pharmacy Specialist (CPS) w/ providing rights defined w/i their scope of practice as agreed upon by there facility. CPS' typically have to have residency training or equivalent experience and sometime also must have board certification. The "equivalent experience" typically means that you have to of have some type of clinical training elsewhere prior to getting the position (it just depends). Caveats of the VA...well pay varies from each facility and since the benefits are so great people rarely leave and since its federal (i.e typically unionized) its hard to get rid of "bad apples" and the good people rarely leave so turnover is very low. Eitherway the clinical functions you can have are far beyond the collaborative practice agreements as you can just have more autonomy for your services to see your own pts and run your own clinic, etc. Another caveat is that the bulk of population aren't veterans so the impact so unless you can set up a training agreement w/ local school of pharmacy then the large majority of population isn't benefitting from your increased capacity as a clinician.

Most recent renewal directive can be found at:
http://www.pbm.va.gov/directive/vhadirec012903.pdf

For anyone else who is still reading this short novel it may also be worthwhile to check out a recent report in AJHP about the future of pharmacists and pharmacy technician work force. Its a little bit far fetched in some regards (w/ various clinical pharmacist ladders and pharm tech evolution), but things are certainly beginning to push in that direction.

Article:
Draft: Long-range vision fo rthe pharmacy work force in hospitals and health-systems. AJHP 2006; 63:661-5.

 

[goodb29]

FamilyMD (Dr. Loser) probably spends alot of time belittling his cousin as well just to boost his own self confidence, Oh and pharmacists can prescribe in 43 states through collaborative practice agreements, but he thinks thats not significant. FYI, doctors were admamently against PAs and NPs in the 1970s as well. (Yea you can keep your 30,000+/year malpractice insurance too, lol)

 

[insipid1979]

goodb29 and kwizard...I was wondering how physicians in the VA hospitals you have worked at view the clinical pharmacists? Are they approving?

 

[goodb29]

They are very accepting and encouraging. We are actually considered as equals in the VA system, because the PharmD is a professional terminal degree and physicians actually dont directly supervise clinical pharmacists. The VA system is set up so that when they have a new HTN patient come in to the system, they are seen by a MD/DO, then they will have a followup appointment with a clinical pharmacist who will monitor their BP, take an H and P and then adjust doses and order lab tests as necessary. It is a very collegial atmosphere at the VA, very welcoming. My friend loved her residency there...

 

[kwizard]

They are very accepting and encouraging. We are actually considered as equals in the VA system, because the PharmD is a professional terminal degree and physicians actually dont directly supervise clinical pharmacists. The VA system is set up so that when they have a new HTN patient come in to the system, they are seen by a MD/DO, then they will have a followup appointment with a clinical pharmacist who will monitor their BP, take an H and P and then adjust doses and order lab tests as necessary. It is a very collegial atmosphere at the VA, very welcoming. My friend loved her residency there...

Agreed. Many of the VAs are have set up various clinics (i.e. CHF, psych, neurology, COPD, smoking cessation, etc.). How you are viewed by medical staff depends on how long and effectively pharmacists have been managing therapy at that facility and how competent one presents themselves. Some MD/NP/PA are more receptive than others. How the clinic is set up for referrals also varies as well so your role w/i that pts care will vary w/ the level of comfort b/w you and the clinicians w/i that discipline.

Caveat is that any of these clinics are typically for those "uncomplicated ambulatory pts (i.e. fairly stable pts)". In particularly when looking at cardiovascular cases when pts are potentially unstable or high level of acuity it may be best and often advisable to work closely w/ MD on f/u or MD may start w/ initial visits/evals until pt stable and then PharmD is referred for continued f/u for chronic therapy. So expanded role for PharmD is typically in realm of chronic care and optimizing care in the chronic setting (i.e improving LDLs, HTN, post CVA prophylaxis, sz control, depression remission, etc.).

Like I said the setting provides a lot of options but I don't want to overembelish as the MD still typically runs the show; however, the PharmD carries signicant weight. But from a liability standpoint you don't want to get in over your head so you've got to realize your comfort zone. I've even ran into situations in private practice where I may be asked to take over a portion of someone's therapy w/ little support from MD so you just have to no when to say "enough is enough" in the best interest of the pt and your own liability. Just a FYI.

 

[goodb29]

FYI as to some very encouraging news for our profession.

http://www.redorbit.com/news/health...dication_advice_to/index.html?source=r_health

 

[genesis09]

In Illinois, there have been several proposals to allow pharmacists to dispense under certain parameters. However, every time, the Illinois Medical Society has managed to quash the proposals. MDs, in general, are against any proposal which would extend what a pharmacist can do.

 

[konkan]

FYI as to some very encouraging news for our profession.

http://www.redorbit.com/news/health...dication_advice_to/index.html?source=r_health

The question is still how/are they gonna bill for these consultations??

 

[kwizard]

The question is still how/are they gonna bill for these consultations??

The billing codes are as follows:

Encounter for therapeutic drug monitoring V58.83 for lab monitoring/clinic visits (this would be you ICD code for reason why patient is being seen)
Chronic therapy (i.e. AC management) I think you then start to use V58.61-58.69.

Procedure you'd bill for would be medication management: CPT Code 0115T (for initial 15min encounter) or 0116T (for follow up 15 min encounter)

I believe these are the codes I've used in the VA previously although not currently in the VA I'm not sure if things have changed. The deficit of pharmacy education is that we too often get caught up in trying to provide a service and fall short in the business side of "How do you get paid for the service provided?"

Another short coming is that many of our administrators are often somewhat detached from clinical progress of the profession and may not realize that advocating for billing for services may be another way to improve pharmacy budgets as opposed to only focusing on pharmacy cost expenditures. Depending on setting (i.e if you weren't on the west coast) the only way to move up in pharmacy 10-20yrs ago was to become an administrator as the clinical avenue was still expanding in many areas (it still is now). So you could then hypothesize how some directors may of lacked clinical experience and just went straight for the administrative job and possibly ignored the potential of the clinical side (which is why you are now having more clinical coordinators or Associate Director of clinical pharmacy positions posted now a days to help develop that side of the pharmacy).

Obviously the billing side has its flaws which need to be improved upon, but we really need to educate each other as a profession how we can improve the education of such services and obtain compensation for such services. VA is a nice template on theory but since many of the veterans already receive federal assistance via their VA benefits medicare reimbursement is not possible b/c that would be "double dipping" so ?I think? billing in VA will only be reimbursed for those pts w/o full VA reimbursement (or none at all) or used as another means for tracking clinical services.

It may be worthwhile to check out the following:
http://www.ashp.org/practicemanager/1d Facility Coding for Clinical Services.pdf

Just my opinion based on my experiences so others are welcome to disagree and feel differently.

 

[sdn1977]

I agree w/Kwizard's thoughts & experience. I think this also works well within the Kaiser system, Indian Health & Public Health Services. Locally, we have a big clinic here that it would work well in too, but it just hasn't happened. My perception is that this works the very best when providers & services are well integrated. It becomes unwieldy & difficult when you have individual provider practices who order lab tests & you are "outside" the structure (not implying a physical structure - a systems structure). Lab tests get sent to the provider & somehow, separately, you need a copy. Same with drug changes...somehow that info needs to get back to the provider. In addition, you have other providers which might want to interface (dentists, specialists, etc) & unless the "communication" is really good - one of you are not on the same page. They use different charting, computer systems, etc...

I may not be explaining myself very well....but when it works, pharmacist involvement of patient management is a great advance - that is the basis for the thought process of the new reimbursement for Medicare Part D. I think it will take awhile before it gets to a widespread community level.

 

[All4MyDaughter]

sdn1977 and kwizard = best posters on SDN

I always feel like I learn so much reading your posts!
Thanks.

 

[ZpackSux]

You know what this is so stupid. I have NEVER posted on this pharm board before but you people are so defensive. Honestly, pharmacists will NEVER prescribe to any significant amount. You guys are great at what you do, cross checking interactions, giving OTC advice to customers, etc., but you can not honestly tell me you have the CLINICAL training to dx. As I said, I am NOT anti-pharm and even have a cousin doing it. Someone said I was bitter???!!! Puh-leez. I have the best job in the world. Wanna talk bitter, everytime I talk to my cousin he says there is not a day he doesn't think of quitting as he stands at the drive thru (a la McDonald's) and has to go fetch the "patient" her charmins. Very demoralizing.
As suggested, I will leave now and post no more, I only posted to correct a blatant error.

LOL.. can't stick to his own words.. Noice..

You can prescribe all you want... but once the Pharmacy Department and the P&T restricts it... you can't get it.. no matter how loud you scream..



You have the best job in the world? LOL ... sure you do.

 

[ZpackSux]

sdn1977 and kwizard = best posters on SDN

I always feel like I learn so much reading your posts!
Thanks.

I resemble that remark..

 

[OHMAN0125]

LOL.. can't stick to his own words.. Noice..

You can prescribe all you want... but once the Pharmacy Department and the P&T restricts it... you can't get it.. no matter how loud you scream..



You have the best job in the world? LOL ... sure you do.

Hello, I'm a pharmd who is in medical school now. Honestly, I don't think pharmacists should be allowed to prescribe to an extensive amount. Being in both schools, the education is very different. Pharmacists may know everything about therapeutic drugs, but diagnosis is actually the key to prescribing. I did not receive any diagnostic skills in pharmacy school. Don't know about any of you here. BUT, I do think it's reasonable for the pharmacist to make reasonable drug/dose switches w/o a doctors direct approval. Again the diagnosis is already made in this case.

 

[WVUPharm2007]

As long as I wind up in a independent pharmacy or a lax hospital pharmacy where I can "prescribe" myself some Augmentin at cost, I'll be fine.

 

[All4MyDaughter]

I resemble that remark..

you would...

 

[MacGyver]

Since when do pharmacists learn physical diagnosis in pharm school?

 

[kwizard]

Since when do pharmacists learn physical diagnosis in pharm school?

I'm really trying not to add fuel to the fire, but perhaps some clarification may be helpful. I think there may be some misunderstanding about the evolution of clinical pharmacy which is understandable given evolution is a difficult process and more often than not even pharmacists disagree about which direction the profession is going.

Pharmacist prescribing will more than likely always be in instances where a diagnosis is already made by a PA/NP/MD. In pharmacy schools pharmacists do receive a fair amount of physical assessment. What you consider a "fair amount" is debatable and shouldn't be compared to what MD/PA/NP receive given the different foci amongst the respective professions. Residency training further develops the clinical expertise of pharmacists in clinical settings. Although pharmacy residency training is still evolving and doesn't compare to the overall intensity of medical residency training, pharmacy residency is likely to become mandatory w/i the next 5-10yrs to further ensure the quality of pharmacists practicing in "clinical settings".

Where pharmacists have flourished in pt care is typically in the realm where a diagnosis is already made and/or there is a change in dz state (i.e. elevated BP, uncontrolled blood sugar, etc) and in these instances the pharmacist has shown the capacity to improve the outcomes of the pt. In many instances based on primary literature the pharmacists have been shown to effectively manage such instances as well as a MD/PA/NP. So in this instance if a pharmacist can manage such dz outcomes than shouldn't the pharmacist also have the ability to prescribe such medications to improve the outcome. If you don't have the power to prescribe than you are continuously making reccomendations for therapy to the provider and the provider may accept the recommendation and then bill for medication management w/ the pharmacist receiving none of that potential for billing (thus providing a free service).

Various examples are in many hospital settings where the pharmacy has the right to manage antibiotic therapy, anticoag (inpt and outpt), antisz meds (dilantin, tegretol, etc) and digoxin. Basically the area of drugs that can be monitoring by drug levels (i.e. therapeutic drug monitoring). However what is frustrating is that if you can perform all of these functions in inpt settings that why can't pharmacist perform them in private sector ambulatory settings and bill for service. As previously mentioned the VA provides a template as do many of the collaborative practice laws within the states, but Medicare revisions of the past yr still kind of undermined pharmacists in the whole "medication management section". In particularly in private sector outpt anticoag it is particularly frustrating that you are managing a pt independent of any provider but when it comes time to change there coumadin you have to give verbal orders on the the MDs behalf (not your own). The same could be said for med management clinics. Basically the argument has always been that pharmacists in pt care settings minimize adverse events and help optimize pt therapy.

There are a lot of position papers and reviews on the ACCP website
http://www.accp.com/position.php
which can definitely state the direction of pharmacy better than I. However, I would only stress that pharmacists are simply trying become recognized for a service we have been providing for some time. We are still the only free advice healthcare professional and many of the "simply questions" are likely to stay in the free advice category (i.e. which cough medicine is best), but in so many capacities we do so much more regardless of practice setting and deserve to be recognized and be able to bill for such services. We are not trying to invade on anyone's territory, but just to be recognized and paid for the area we occupy so we can optimize its potential and optimize pt care.

Sorry again for the length as I always have a little too much to say.

 

[sdn1977]

Kwizard - I am really not stalking you, but I seem to be always following your posts 🙂 ! Again - a very clear explanation....

On an interesting aside on this very topic...I just returned from a vacation in Canada...and the pharmacists in British Columbia just received authority to "prescribe" limited medications which will begin in 2007. The information presented was very limited (I read it in their newspaper) & I really did have more interesting things to occupy my time 😉 ...but..perhaps our Canadian BC pharmacists can add to this. Apparently, these are maintenance medications, but there seem to be provisions for others as well. This is allowed only in BC - not the other provinces.

Perhaps this is in response to the problem they have with timely access to healthcare which is a huge issue in that country as well as the number of remote rural areas with limited physician coverage. Again...this is really sketchy - I'd give you the link, but I can't remember for sure - I think it was reported in the Vancouver Sun.

 

[tackett26]

Just out of curiosity...what would your opinion be if someone tried to let physicians be able to prescribe and dispense drugs themselves at their practice?

They Can!!!!!!!!!!!!!!!

See: http://www.ncbop.org/dispphys_regreq.htm
See: http://www.allbusiness.com/services/health-services-offices-clinics-doctors/4968406-1.html

And do a Google Search! You'll find millions of others.

 

[tackett26]

Google Pharmacy Residency... And it would be easy to set up programs to allow bridging between these two fields.

Take King's College in London for instance (those of you who are fellow history buffs like me know this is the University where Watson and Crick discovered the structure of DNA- this is NOT a no name university): They have set up a program geared toward bridging pharmacy and medicine.

See this link: http://www.kcl.ac.uk/schools/biohealth/depts/pharmacy/pgt/supplprrescribing-info.html

I agree...I believe there would be a huge mess if all pharmacists were allowed to prescribe. Pharmacists who have done 2 yrs of residency training are well prepared and know their speciality inside and out. I recommend prescribing power for these clinical pharmacists.

 

[tjaze]

VA hospitals also offer something similar to this. I wonder if any other states have current laws in the works too?

this stuff is getting ridiculous. people should do what they have expertise in. as a 3rd yr med student, i'm just realizing how much i DONT know. if you're not a board certified physician, you should not be diagnosing. most people have simple things, but someone undertrained will miss the rare and deadly case. med students get a weak pharm course, so i guess we pick everything up in residency. but a pharmacists input on med management would be invaluable. nonetheless, we need to stop blurring the lines of professional duties and abilities or it will be detrimental to certain patients.

 

[tackett26]

this stuff is getting ridiculous. people should do what they have expertise in. as a 3rd yr med student, i'm just realizing how much i DONT know. if you're not a board certified physician, you should not be diagnosing. most people have simple things, but someone undertrained will miss the rare and deadly case. med students get a weak pharm course, so i guess we pick everything up in residency. but a pharmacists input on med management would be invaluable. nonetheless, we need to stop blurring the lines of professional duties and abilities or it will be detrimental to certain patients.

Well that's brilliant. Here's a guy going into cardiac arrest. But I shouldn't do CPR because I'm just a pharmacist! Call Cardiology!

 

[ontheair]

Just out of curiosity...what would your opinion be if someone tried to let physicians be able to prescribe and dispense drugs themselves at their practice?

alot of doctors do that..........like they dispense latisse , or any other cosmetic creams. they give out samples...
so I think pharmacist should beable to prescrib. bc we go over all the disease states and everything in depth. so funny that we cant even presribe for ourselves and even though we know the dx and we know the Tx we have to go to md. This just doesnt make sense.

 

[Praziquantel86]

this stuff is getting ridiculous. people should do what they have expertise in. as a 3rd yr med student, i'm just realizing how much i DONT know. if you're not a board certified physician, you should not be diagnosing. most people have simple things, but someone undertrained will miss the rare and deadly case. med students get a weak pharm course, so i guess we pick everything up in residency. but a pharmacists input on med management would be invaluable. nonetheless, we need to stop blurring the lines of professional duties and abilities or it will be detrimental to certain patients.

I tend to agree with you, but just to play Devil's Advocate:

By your own admission, medical students don't learn everything about pharmacology in medical school. They pick up this knowledge during residency, which then makes them competent prescribers. Pharmacists receive minimal diagnostic training in pharmacy school. Those that are granted diagnostic rights do so after additional residency training. Why can't it work both ways for you?

Also, non board-certified physicians diagnose all the time. They're called residents and fellows.

Like I said, I agree with you. Just thought I'd throw that out there.

 

[womp]

Well that's brilliant. Here's a guy going into cardiac arrest. But I shouldn't do CPR because I'm just a pharmacist! Call Cardiology!

Woosh! That's the sound of tjaze's point passing over your head.

 

[bananaface]

this stuff is getting ridiculous. people should do what they have expertise in. as a 3rd yr med student, i'm just realizing how much i DONT know. if you're not a board certified physician, you should not be diagnosing.

Pharmacists at the VA aren't diagnosing, but prescribing for conditions diagnosed by the physician. You should know that before you spend too much effort trying to debate over diagnosis.

 

[tackett26]

Woosh! That's the sound of tjaze's point passing over your head.

I think it is you who is missing my point! I hoped using an extreme example would serve the point but apparently not! My point is all of the health care disciplines are going to overlap somewhere! Thus the reason they all fall under the broad umbrella of "health care disciplines!"

The point I'm trying to make is that cross training between disciplines will enable individual health care providers (that is to say physicians, nurses, pharmacists, Physicians assistants, clinical laboratory scientists) to work with one another more smoothly!

Sig. Read 3x and ensure through understanding before posting reply! Reread PRN.

 

[spacecowgirl]

Whoa, this was a blast from the past. And funny I said I never wanted to prescribe because I do now. Only with a diagnosis from someone trained in that, of course.

 

[MountainPharmD]

Wow....Talk about digging up old dirt. This forum has not been the same since sdn1977 got kicked off. At least Z-pack is still here...I guess that is a good thing.

 

[tjaze]

I tend to agree with you, but just to play Devil's Advocate:

By your own admission, medical students don't learn everything about pharmacology in medical school. They pick up this knowledge during residency, which then makes them competent prescribers. Pharmacists receive minimal diagnostic training in pharmacy school. Those that are granted diagnostic rights do so after additional residency training. Why can't it work both ways for you?

Also, non board-certified physicians diagnose all the time. They're called residents and fellows.

Like I said, I agree with you. Just thought I'd throw that out there.

first, residents and fellows DIAGNOSE AND PRESCRIBE under the supervision of an attending. if there is any mistake, the attending is responsible.

second, you make a reasonable point about picking up one thing along the way, but med students still have a good enough foundation of pharm not to do something dangerous. by the time we're residents, we actually have a very good foundation of common drugs. but diagnosis is something that takes a lifetime to master. pharm students are not given enough time to practice history taking and physical exam. and it's years of experience that gives you the foundation to ask EVERY important question every time. like i said before, i'm just realizing how far i still have to go before i can work unsupervised. i don't see how you can have a pharm student pick up how to do great H&Ps in just one or two years of residency. but i can't say for sure since i don't know how extensive your training in path/pathophys, anatomy, neuro, etc is.

 

[gotdrugs]

first, residents and fellows DIAGNOSE AND PRESCRIBE under the supervision of an attending. if there is any mistake, the attending is responsible.

second, you make a reasonable point about picking up one thing along the way, but 1. med students still have a good enough foundation of pharm not to do something dangerous. 2. by the time we're residents, we actually have a very good foundation of common drugs. but diagnosis is something that takes a lifetime to master. pharm students are not given enough time to practice history taking and physical exam. and it's years of experience that gives you the foundation to ask EVERY important question every time. like i said before, i'm just realizing how far i still have to go before i can work unsupervised. 3. i don't see how you can have a pharm student pick up how to do great H&Ps in just one or two years of residency. 4. but i can't say for sure since i don't know how extensive your training in path/pathophys, anatomy, neuro, etc is.

In response to the bolded parts.

1. You are extremely. effing. naive/dumb/blind/stupid/fill in blank if you think med students, residents, fellows (and sometimes even attendings) don't make very dangerous prescribing errors because they they possess just enough *comparatively little* knowledge about medications to make them extremely dangerious.

2. Actually - from the hundreds of medical and surgical residents I've worked with, no you don't. Sorry, it's not true.

3. I would agree that I could never do an H&P as well as most (if not all) upper-year residents, fellows or attendings. But more on this in a minute

4. If you don't know squat about how pharmacists are trained then why are you making these silly statements?

Back to #3 - I do agree with you in principle but two things, the true intent of collaborative practice was never for pharmacists to diagnose, but to manage the medication therapy after you guys have done that. You guys are much better at diagnosing than us, but we are better at managing medication therapy than you.....sorry if that latter part hurts your ego a little bit but it's true.

And one last thing......while we may not have that training MD/DOs do in this aspect, you should check out the training of pharmacists vs. the training of NPs and PAs and then get back to us.

The sad part of it (for pharmacy anyways) is that unless financial reimbursement becomes viable, it'll never become widespread so all of this bickering is for squat.

 

[Praziquantel86]

first, residents and fellows DIAGNOSE AND PRESCRIBE under the supervision of an attending. if there is any mistake, the attending is responsible.

second, you make a reasonable point about picking up one thing along the way, but med students still have a good enough foundation of pharm not to do something dangerous. by the time we're residents, we actually have a very good foundation of common drugs. but diagnosis is something that takes a lifetime to master. pharm students are not given enough time to practice history taking and physical exam. and it's years of experience that gives you the foundation to ask EVERY important question every time. like i said before, i'm just realizing how far i still have to go before i can work unsupervised. i don't see how you can have a pharm student pick up how to do great H&Ps in just one or two years of residency. but i can't say for sure since i don't know how extensive your training in path/pathophys, anatomy, neuro, etc is.

I've got to disagree with you on your point about knowing enough pharmacology to not make a dangerous mistake. There are thousands of clinically significant drug interactions out there, and some of them are pretty darn esoteric. There's no way that anyone, let alone an intern fresh out of medical school, can keep track of all of them. Pharmacists don't know them all either, but they know an awful lot more about kinetics and dynamics so that the interactions are more easily predicted.

You're also a little off base on the H&P statement. Many pharmacy schools have a full physical assessment curriculum that is integrated over the duration of school. Standardized patients, interviews, the whole lot. The training wouldn't "just" be a year or two of residency, but also a significant chunk of school.

But, like I said, I agree with you. Diagnosis should remain up to the physician - although pharmacists do have some training in it, the physician's is much better. I just don't see a problem with a pharmacist prescribing/altering therapy after the physician has made a diagnosis and initiated treatment.

 

[WVUPharm2007]

but diagnosis is something that takes a lifetime to master. .

With all due respect for the intricacies of diagnosis, I can honestly say that the same can be said for selection of drug therapy. I'll see physicians with decades of experience show utter incompetence at prescribing. I'm talking the family practice physician that comes in and orders enalaprilat 12.5mg IV PRN for Elevated BP...because that's what the oral dose is...or the physician that converts PO to IV Synthroid at a 1-to-1 ratio...you know...those little details that only a person whose entire career revolves around drug therapy readily recognizes...

I'm not particularly saying that RPhs should diagnose...I really don't care because I'm not interested in it...but to say that the intricacies of diagnosis are so complex while ignoring the fact that if I wasn't at the hospital playing copy editor for the physicians whose drug expertise is frequently much less than "master" level...yes...people WOULD DIE...but, yet, being devoid of mastery is fine insofar as with physicians having prescriptive authority? But it doesn't work both ways on some other part of the process? The difference is that pharmacists are around to account for poor prescribing...an independent pharmacist doesn't have a diagnostic expert to account for below par judgment in a physical examination. Until the robots with circuity superior to humans comes around. Then we could definitely do it.

From a philosophical perspective, I'm sorry to say you are wide right in the field goal of arguing.

Though I agree that RPhs shouldn't diagnose. Frankly, I'm not interested in boring ass **** like that, anyway. I just like pharmacology and drugs...hells yeah...y'all can stick your noses 5 feet away from an anal fissure for proper diagnosis...more power to you...not to mention the fact that I rather enjoy my malpractice only being $120 a year. It's not like our salaries would go up enough to pay off our new-found god awful premiums. Even though I honestly think we could with the amount of training PAs and NPs get on the subject. Be honest...it isn't that conceptually complex. Nothing in healthcare is as conceptually complex as we all pretend it is...

But..yeah...I think it's a bad idea...moreso for us than for the patients...

 

[meister]

I'll see physicians with decades of experience show utter incompetence at prescribing. I'm talking the family practice physician that comes in and orders enalaprilat 12.5mg IV PRN for Elevated BP...because that's what the oral dose is...or the physician that converts PO to IV Synthroid at a 1-to-1 ratio...you know...those little details that only a person whose entire career revolves around drug therapy readily recognizes...

...and this is why within the next decade community physicians and especially family docs will lose hospital privileges. Hospitalists run the show in a lot of places, it isn't 1975 anymore. Stuff is a lot more complex now.

 

[WVUPharm2007]

...and this is why within the next decade community physicians and especially family docs will lose hospital privileges. Hospitalists run the show in a lot of places, it isn't 1975 anymore. Stuff is a lot more complex now.

Never going to happen in the rural setting. My hospital can barely afford the two hospitalists they have...and the area created 150-180 inpatients on any given day. They need random ass people out yonder that can just bill the system.

 

[meister]

Heh yeah you're right about that. Something like 2/3s of the American population live in underserved areas.

Any idea if those two guys are raking it in? Any opinion on their acuity?

 

[PharmacistReb]

Pharmacists are drug experts. Though we'd be very knowledgeable about what drugs to prescribe for certain diseases, the problem would be determining the patient's disease state. Pharmacists are not diagnosticians. We've very little training in diagnostics.

You could only imagine how much more antibiotic resistance we would create if pharmacists were prescribing without any diagnostic ability. Not to mention the increased liability, etc.

Bad idea if you asked me.

 

[Priapism321]

Pharmacists are drug experts. Though we'd be very knowledgeable about what drugs to prescribe for certain diseases, the problem would be determining the patient's disease state. Pharmacists are not diagnosticians. We've very little training in diagnostics.

You could only imagine how much more antibiotic resistance we would create if pharmacists were prescribing without any diagnostic ability.

Bad idea if you asked me.

Stupid and probably inaccurate statement. As a matter of fact, there is data supporting that a pharmacist's selection of antimicrobial therapy is superior to an Infectious Diseases Fellow's (ie, an individual who has been a physician for 3 years, see Gross R, et al. Clin Infect Dis 2001;33:289-95). Also, pharmacists trained in ID Pharmacotherapy are hired specifically to help combat and reduce antimicrobial resistance by promoting evidence based drug selection (among other things that are beyond the scope of my post) in many of the top health-systems in the country.

 

[Quiksilver]

I think it is you who is missing my point! I hoped using an extreme example would serve the point but apparently not! My point is all of the health care disciplines are going to overlap somewhere! Thus the reason they all fall under the broad umbrella of "health care disciplines!"

The point I'm trying to make is that cross training between disciplines will enable individual health care providers (that is to say physicians, nurses, pharmacists, Physicians assistants, clinical laboratory scientists) to work with one another more smoothly!

Sig. Read 3x and ensure through understanding before posting reply! Reread PRN.

why do you resurrect 3 year old threads all the time?

I think the guy had a valid point. Diagnosis is left for the physician and to handle, personally i don't want the liability that that brings. I am happy to suggest possible pathophysiological problems that are occuring, but by no means am I an all-star at it. By the same token, I am a pro at medications, I know how to dose, I know how to pick the right medication and that parallels how a doctor knows how to diagnose. Tjaze is making that point. Like a physician specializes into cardiology, nephrology, neurology; we specialize in medications

Usually, if there is a guy is in cardiac arrest in the hospital you usually use a thing called ACLS. Its a little more effective then CPR alone.

 

[tjaze]

In response to the bolded parts.

1. You are extremely. effing. naive/dumb/blind/stupid/fill in blank if you think med students, residents, fellows (and sometimes even attendings) don't make very dangerous prescribing errors because they they possess just enough *comparatively little* knowledge about medications to make them extremely dangerious.

2. Actually - from the hundreds of medical and surgical residents I've worked with, no you don't. Sorry, it's not true.

3. I would agree that I could never do an H&P as well as most (if not all) upper-year residents, fellows or attendings. But more on this in a minute

4. If you don't know squat about how pharmacists are trained then why are you making these silly statements?

Back to #3 - I do agree with you in principle but two things, the true intent of collaborative practice was never for pharmacists to diagnose, but to manage the medication therapy after you guys have done that. You guys are much better at diagnosing than us, but we are better at managing medication therapy than you.....sorry if that latter part hurts your ego a little bit but it's true.

And one last thing......while we may not have that training MD/DOs do in this aspect, you should check out the training of pharmacists vs. the training of NPs and PAs and then get back to us.

The sad part of it (for pharmacy anyways) is that unless financial reimbursement becomes viable, it'll never become widespread so all of this bickering is for squat.

you make a good point about dangerous prescribing errors. however, the reason for those errors can't be assumed to be because of inadequate knowledge. i'm sure a good deal of it comes from laziness to check interactions, fatigue, rushing through things, etc. i know for sure that i would double check in a reference before changing anything in a complex patient and if i wasn't sure, I'D ASK THE PHARAMCIST. my ego is not that important to me. and notice i didn't say we knew enough to create a perfect regimen, but that if you take the time and research before you prescribe, a med student should be able to not kill the patient.

i also made the mistake of assuming that if the pharmacist was prescribing, he/she would also be diagnosing or it would be a one stop visit. my bad. it definitely makes sense that the pharmacist would put together a better treatment regimen.

but concerning the H&P and pharmacy curriculum, i do know a reasonable amount. my best friend is in pharmacy school and is a top student, so i have a good idea what he went through. they were taught auscultation by nurses. we're taught auscultation by a nationally recognized cardiologist. i just don't know exactly how indepth your diagnosis knowledge is. and no matter how much history or physical training you get on a standardized patient, it takes several months of 60 hr weeks to get to an acceptable level.

and don't get me started on np/pa. everyone wants the status and money and no one wants to do the work. if they had their way, they would be our bosses.

 

[Aggie07]

http://www.ascp.com/publications/tcp/1996/sep/collab.html

 

[tackett26]

why do you resurrect 3 year old threads all the time?

I think the guy had a valid point. Diagnosis is left for the physician and to handle, personally i don't want the liability that that brings. I am happy to suggest possible pathophysiological problems that are occuring, but by no means am I an all-star at it. By the same token, I am a pro at medications, I know how to dose, I know how to pick the right medication and that parallels how a doctor knows how to diagnose. Tjaze is making that point. Like a physician specializes into cardiology, nephrology, neurology; we specialize in medications

Usually, if there is a guy is in cardiac arrest in the hospital you usually use a thing called ACLS. Its a little more effective then CPR alone.

I am familiar with Advanced Cardiac Life Support and yes it is more effective. But you are still missing my point. There is bleed over between the medical professions. That is not a bad thing, but rather a good thing. It will enable us to work together.

Also if you don't think the thread is current enough to read about, don’t post on it! It’s that simple!

 

[Quiksilver]

I am familiar with Advanced Cardiac Life Support and yes it is more effective. But you are still missing my point. There is bleed over between the medical professions. That is not a bad thing, but rather a good thing. It will enable us to work together.

Also if you don't think the thread is current enough to read about, don’t post on it! It’s that simple!

you certainly made it out to be a bad thing with your outstanding example you used.

The thread is still very current but you are acting if these people still post and that you were in the conversation from the get go. I mean you resurrected this thread by posting a reply to someone's question. Perhaps in the 3 years between the original posting and your reply, people found the answer. Its that simple!