Pharmacists as a means of countering Physician Shortage?

[pharmadentist]

Hello All,

So this will be a weird discussion to some extent. It's only a hypothetical idea that came in my mind, but I found it interesting. Before I begin, I'll ask everyone to keep this discussion civilized. All professions deserve respect and everyone (Pharmacists, PA's, Nurses, NP's, Physicians) has sacrificed time and put in effort to get to their positions. There is no need to use any profane language or insult anyone for their opinions. I hope this can be a civilized discussion.

As we all know, the Physician shortage in rural areas, specifically amongst general care practitioners, namely Family Medicine and Internal Medicine Physicians, is something that cannot be understated. Even in the USA, with seemingly many doctors graduating each year, this shortage remains a tremendous problem.

Additionally, Pharmacists have been facing an increasingly difficult job market, caused by over-saturation. Nonetheless, Pharmacists are extremely well-trained in many aspects of patient care, including drug reactions, vaccinations, etc.

The different in training between MD/DO's and PharmD's is significant. They are both trained for different purposes and different job descriptions - this cannot be stated enough.

However, can Pharmacists be trained through specifically designed residency programs to become the equivalents of Internal Medicine or Family Medicine Physicians? Can this be a potential solution to both the dire rural physician shortage and the over-saturation of Pharmacists?

As a disclaimer, careers such as as NP and PA do exist, and are extremely valuable to the health care team. However, they are both not independent practitioners, and thus are not a fully feasible solution.

Pharmacists can advice patients on various types of allopathic treatment, refer cases to other practitioners if needed, and manage a health care team. Additionally, the PharmD is a highly respected degree (not to say others aren't), so such a preposition is indeed feasible.

I have utmost respect for Physicians and their respective training. I do not want this post to come across as a proposal for an infringement on that noble profession. I hope that no one finds offence to this post and if they do, please forgive me as that wasn't my intention. My intention is to have a healthy discussion highlighting both the feasibility, and infeasibility of such a preposition.

How can such a preposition be carried out?

Organizations like the AACP and APA can firstly engage politically in order to have this type of preposition realized and acknowledged.

Then, partnerships with hospitals can occur to develop extended residency programs, like 4-5 years in length, to train Pharmacists. I understand that PharmD/MD programs do exist, however, that pathway is lengthy and there needs to be a better bridge.

So I'm interested to hear from the respective professionals on this forum, what are your thoughts? Once again, I ask all to refrain from any type of name-calling or profanity, and engage in a civilized and healthy discussion.

Thanks everyone!

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[bacillus1]

I don't think so...pharmacists aren't really trained in diagnosis that much during their education. I think taking the role of a mid-level is acceptable in some instances, however keep in mind that everyone and their mother is now opening up a PA school citing a physician shortage, and PAs are cheaper.

 

[radio frequency]

The diagnosing side of my education was laughably small. I think pharmacists could move into these roles with different training, but there would have to be some serious diagnostic focus of a residency...

 

[pharmadentist]

I don't think so...pharmacists aren't really trained in diagnosis that much during their education. I think taking the role of a mid-level is acceptable in some instances, however keep in mind that everyone and their mother is now opening up a PA school citing a physician shortage, and PAs are cheaper.

Thanks for your reply and insight. I didn't know that the Pharmacy education didn't emphasize diagnosis much. It's also interesting that you note that PA's are a less costly alternative. Makes sense.

 

[pharmadentist]

The diagnosing side of my education was laughably small. I think pharmacists could move into these roles with different training, but there would have to be some serious diagnostic focus of a residency...

Thanks for your reply. It's nice to hear from someone who has had that education and can analyze such a preposition. I get what you are saying and it seems like it isn't as feasible as I thought given the significant differences in training.

 

[CetiAlphaFive]

Hello All,

So this will be a weird discussion to some extent. It's only a hypothetical idea that came in my mind, but I found it interesting. Before I begin, I'll ask everyone to keep this discussion civilized. All professions deserve respect and everyone (Pharmacists, PA's, Nurses, NP's, Physicians) has sacrificed time and put in effort to get to their positions. There is no need to use any profane language or insult anyone for their opinions. I hope this can be a civilized discussion.

As we all know, the Physician shortage in rural areas, specifically amongst general care practitioners, namely Family Medicine and Internal Medicine Physicians, is something that cannot be understated. Even in the USA, with seemingly many doctors graduating each year, this shortage remains a tremendous problem.

Additionally, Pharmacists have been facing an increasingly difficult job market, caused by over-saturation. Nonetheless, Pharmacists are extremely well-trained in many aspects of patient care, including drug reactions, vaccinations, etc.

The different in training between MD/DO's and PharmD's is significant. They are both trained for different purposes and different job descriptions - this cannot be stated enough.

However, can Pharmacists be trained through specifically designed residency programs to become the equivalents of Internal Medicine or Family Medicine Physicians? Can this be a potential solution to both the dire rural physician shortage and the over-saturation of Pharmacists?

As a disclaimer, careers such as as NP and PA do exist, and are extremely valuable to the health care team. However, they are both not independent practitioners, and thus are not a fully feasible solution.

Pharmacists can advice patients on various types of allopathic treatment, refer cases to other practitioners if needed, and manage a health care team. Additionally, the PharmD is a highly respected degree (not to say others aren't), so such a preposition is indeed feasible.

I have utmost respect for Physicians and their respective training. I do not want this post to come across as a proposal for an infringement on that noble profession. I hope that no one finds offence to this post and if they do, please forgive me as that wasn't my intention. My intention is to have a healthy discussion highlighting both the feasibility, and infeasibility of such a preposition.

How can such a preposition be carried out?

Organizations like the AACP and APA can firstly engage politically in order to have this type of preposition realized and acknowledged.

Then, partnerships with hospitals can occur to develop extended residency programs, like 4-5 years in length, to train Pharmacists. I understand that PharmD/MD programs do exist, however, that pathway is lengthy and there needs to be a better bridge.

So I'm interested to hear from the respective professionals on this forum, what are your thoughts? Once again, I ask all to refrain from any type of name-calling or profanity, and engage in a civilized and healthy discussion.

Thanks everyone!

This is what was supposed to have happened way back when.

Instead, our crappy lobbying groups got us dispensing fees and they created PAs to fill the gap

EDIT: I'd say half of the community mid levels I encounter are garbage.
A pharmacist could easily do their job.

 

[Lnsean]

No. There isn't a shortage of physicians. The problem is distribution, and PAs/NPs are filling that gap.

 

[gwarm01]

A five year residency to accomplish what a PA does in two years of school is such a poor value. I bet pharmacists would be tripping over themselves for the prestige.

Edit: I think the mandatory PharmD was meant to accomplish this but it obviously didn't happen.

I would suggest an additional year of school to cover any classes that are taught in PA school that pharmacy school doesn't cover. Maybe do this the P4 year then require mandatory residency training to achieve an advanced license.

 

[Digsbe]

I'd say a 1-2 year academic program enhancing diagnostic education with scheduled rotations would be adequate. I think more formal instruction than a residency should be required, should be more of a certificate training program or degree.

Right now I think pharmacists should be managing chronic conditions and managing pharmacotherapy. A pharmacist is well equipped to manage diabetes, HTN, HLD, and other very common chronic conditions.

 

[Carol is Alpha]

"However, can Pharmacists be trained through specifically designed residency programs to become the equivalents of Internal Medicine or Family Medicine Physicians? Can this be a potential solution to both the dire rural physician shortage and the over-saturation of Pharmacists? "

Absolutely not. There are no shortcuts for this. I suggest reading some of the allopathic threads about this mission creep issue. I just shake my head when I hear this stuff. What are they selling these kids in pharmacy school? I'm surprised Ramsey hasn't jumped all over this.

 

[deleted480308]

nope

 

[Mad Jack]

I'd say a 1-2 year academic program enhancing diagnostic education with scheduled rotations would be adequate. I think more formal instruction than a residency should be required, should be more of a certificate training program or degree.

Right now I think pharmacists should be managing chronic conditions and managing pharmacotherapy. A pharmacist is well equipped to manage diabetes, HTN, HLD, and other very common chronic conditions.

Patients with chronic conditions usually aren't simple to manage, often have multiple comorbidities, and generally are considered the most difficult (as well as the most tedious and risky) to manage. There's a reason most FM physicians bump off their older patients with multiple issues to internists. They're a pain in the ass, and one mistake this way or that dumps them into the hospital.

 

[rxdawg21]

Patients with chronic conditions usually aren't simple to manage, often have multiple comorbidities, and generally are considered the most difficult (as well as the most tedious and risky) to manage. There's a reason most FM physicians bump off their older patients with multiple issues to internists. They're a pain in the ass, and one mistake this way or that dumps them into the hospital.

Hmm...patients with multiple comorbidities are already managed at the VA by pharmacists, in fact physicians dump them to a pharmacist when they can't get their issues under control themselves (diabetes, HF, dyslipidemia, HTN, COPD, gout, etc). It is clear that pharmacists can do this and do this in certain settings. I even know ambulatory care pharmacists that didn't do a residency doing this. Don't see the issue there.

 

[Mad Jack]

Hmm...patients with multiple comorbidities are already managed at the VA by pharmacists, in fact physicians dump them to a pharmacist when they can't get their issues under control themselves (diabetes, HF, dyslipidemia, HTN, COPD, gout, etc). It is clear that pharmacists can do this and do this in certain settings. I even know ambulatory care pharmacists that didn't do a residency doing this. Don't see the issue there.

They're not managed that way because it is high quality care, they're managed that way because it saves money. Just because you technically can do something doesn't mean you should or will be competent at it.

 

[rxdawg21]

They're not managed that way because it is high quality care, they're managed that way because it saves money. Just because you technically can do something doesn't mean you should or will be competent at it.

Well I don't personally do it. The people I know that do it are very good, have great success rates with getting A1c at goal, BP at goal, controlling hf symptoms by following guidelines and keeping up to date on new research and clinical trials. You know being a competent practitioner. I would much rather manage my conditions personally, then a PA or NP. That's just me.

With stuff I have seen providers do (NP, PA, MD) I think it is much less about what is your job title and more about your ability to stay up to date and educated, and independently evaluate results and not listen to a drug rep.

 

[CetiAlphaFive]

Patients with chronic conditions usually aren't simple to manage, often have multiple comorbidities, and generally are considered the most difficult (as well as the most tedious and risky) to manage. There's a reason most FM physicians bump off their older patients with multiple issues to internists. They're a pain in the ass, and one mistake this way or that dumps them into the hospital.

Oh give me a break.

The average FM doc really isn't performing any miracles

 

[Mad Jack]

Well I don't personally do it. The people I know that do it are very good, have great success rates with getting A1c at goal, BP at goal, controlling hf symptoms by following guidelines and keeping up to date on new research and clinical trials. You know being a competent practitioner. I would much rather manage my conditions personally, then a PA or NP. That's just me.

With stuff I have seen providers do (NP, PA, MD) I think it is much less about what is your job title and more about your ability to stay up to date and educated, and independently evaluate results and not listen to a drug rep.

I'll just put it this way- you've got a guy with DM II, hypertension, hyperlipidemia, and CHF. He presents for a standard med adjustment, but complains of dizziness for the past two days. What is your initial differential? What exams do you perform? This is basic diagnosis and management stuff, and I'd bet the vast majority of pharmacists wouldn't even know where to begin, what exams to perform, what tests to order. etc.

 

[Mad Jack]

Oh give me a break.

The average FM doc really isn't performing any miracles

Spend a couple weeks in a FM practice seeing all of their patients before you judge. The vast majority of people have no idea how broad the variety of complaints, presentations, procedures, and differentials FPs deal with. It's easy to be a terrible FP, sure. But a lot of them are damn good at their jobs. In one rotation I saw three good catches, all the sorts of diseases that you see five or six times in a lifetime, because the FP knew his ****, saving the patients a lot of wasted time and money being bounced around to specialists.

 

[pharmadentist]

Thanks for the comments everyone. I see what y'all are pointing at. The gap between pharmacy and medical training are significantly different. In my little experience interacting with pharmacists though, I notice a pharmacist can at least "prescribe" - so to speak - an effective medicine or treatment if symptoms are told to them or observed by them.

 

[rxdawg21]

I'll just put it this way- you've got a guy with DM II, hypertension, hyperlipidemia, and CHF. He presents for a standard med adjustment, but complains of dizziness for the past two days. What is your initial differential? What exams do you perform? This is basic diagnosis and management stuff, and I'd bet the vast majority of pharmacists wouldn't even know where to begin, what exams to perform, what tests to order. etc.

I don't feel like that would be very difficult to learn through on the job training/residency. I do know that it can be caused by hypoglycemia, postural hypotension, and irregular heart rhythm. I would rule out the first two before proceeding to order an EKG.

At the VA you are managing their disease states with their medications, if it is more complicated then hypoglycemia or postural hypotension which would result in medication adjustments you would then refer them back to their PCP or appropriate specialist. Nothing wrong with that, the fact most pharmacists won't know where to begin is due to the lack of use of the clinical knowledge they learn in school or failure to keep up to date. In some cases it will also be competence issues for whatever reason, that every profession is bound to have.

 

[rxdawg21]

Spend a couple weeks in a FM practice seeing all of their patients before you judge. The vast majority of people have no idea how broad the variety of complaints, presentations, procedures, and differentials FPs deal with. It's easy to be a terrible FP, sure. But a lot of them are damn good at their jobs. In one rotation I saw three good catches, all the sorts of diseases that you see five or six times in a lifetime, because the FP knew his ****, saving the patients a lot of wasted time and money being bounced around to specialists.

That is good to hear, you also hear the horror stories of people being bounced around and they can't find out what's wrong with them. On my rotations I observed a middle age black man be transported to my hospital from another town. He had gone to the ER multiple times to be diagnosed with bronchitis and sent home with appropriate treatment (main complaint coughing and shortness of breath). After the second ER trip and the subsequent steroid taper he had severe edema and was sent to our hospital. I was in the room with the hospitalist when he listened to the patients heart with a stethoscope. He immediately identified a murmur and had an echo ordered, the patient had a mitral valve regurgitation and also had HF (can't remember his EF but pretty sure <40%).

So this man went to the ER multiple times and never had his heart listened to or checked when complaining of shortness of breath and coughing. (if they did do this and missed the heart issue that is just as bad as my physician literally caught it right away). All fields have good and bad practitioners, I am not advocating pharmacists diagnose, we aren't trained that way, we are trained to optimize drug therapy, switch drug classes based on response and side effects and manage diagnosed disease states. All these things would better care and take a load off the MD's plate. Not all pharmacists are competent enough to do this, require a certification similar to BCPS.

 

[pharmadentist]

In general, I personally feel that in rural areas, especially in small towns where there's only a Pharmacist or two, the Pharmacist has enough trust by patients (it's only natural in that scenario), and if given a couple years more of training in basic diagnosis, can at least handle basic cases or otherwise refer them. But, you guys know better - I'm no expert by any means.

 

[bacillus1]

Hmm...patients with multiple comorbidities are already managed at the VA by pharmacists, in fact physicians dump them to a pharmacist when they can't get their issues under control themselves (diabetes, HF, dyslipidemia, HTN, COPD, gout, etc). It is clear that pharmacists can do this and do this in certain settings. I even know ambulatory care pharmacists that didn't do a residency doing this. Don't see the issue there.

Yes...pharmacists at the VA manage patients, but only certain very targeted disease states, serving as a "midlevel provider". They do not serve as a PCP.

 

[rxdawg21]

Yes...pharmacists at the VA manage patients, but only certain very targeted disease states, serving as a "midlevel provider". They do not serve as a PCP.

I never said that. That post was in response to this post by Mad Jack.

Patients with chronic conditions usually aren't simple to manage, often have multiple comorbidities, and generally are considered the most difficult (as well as the most tedious and risky) to manage. There's a reason most FM physicians bump off their older patients with multiple issues to internists. They're a pain in the ass, and one mistake this way or that dumps them into the hospital.

which was in response to this post by Digsbe.

Right now I think pharmacists should be managing chronic conditions and managing pharmacotherapy. A pharmacist is well equipped to manage diabetes, HTN, HLD, and other very common chronic conditions.

All the disease states listed in the post you quoted by me are managed by the ambulatory care pharmacists at my VA. Not sure what new information you provided to the topic.

 

[Sine Cura]

Just FYI to the OP, nurse practitioners are independent practitioners in at least 19 states (most in Pacific time or Mountain time) and at least in AZ there is no restriction on CII prescribing.

 

[radio frequency]

Just FYI to the OP, nurse practitioners are independent practitioners in at least 19 states (most in Pacific time or Mountain time) and at least in AZ there is no restriction on CII prescribing.

NPs have been independent practitioners in every state I've ever lived in. I think we'll see more NPs practicing in the future. Their quality seems a lot more variable than MD quality though (some amazing...some not!).

 

[BenJammin]

NPs have been independent practitioners in every state I've ever lived in. I think we'll see more NPs practicing in the future. Their quality seems a lot more variable than MD quality though (some amazing...some not!).

That's how it is in Texas, sort of. NPs legally don't have independent practice rights but there are older physicians who allow them to use their license to stay legal. He comes in once a week to sign off on charts, sign C2s, and get his paycheck.

 

[radio frequency]

That's how it is in Texas, sort of. NPs legally don't have independent practice rights but there are older physicians who allow them to use their license to stay legal. He comes in once a week to sign off on charts, sign C2s, and get his paycheck.

Most other states don't even require that. That's how PAs have had to practice everywhere I've lived.

 

[CetiAlphaFive]

That's how it is in Texas, sort of. NPs legally don't have independent practice rights but there are older physicians who allow them to use their license to stay legal. He comes in once a week to sign off on charts, sign C2s, and get his paycheck.

That's the case at literally every pain clinic I've ever encountered.

In only one case did the M.D. get punished and their dea # stripped

 

[steveysmith54]

I am still waiting for pharmacists to start handing out birth control in CA.