If the air force allowed pilots to be mechanics for aircraft with lots of success, would that change your mind?
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Physicians Opposing Pharmacist Expanded Practice
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If the air force allowed pilots to be mechanics for aircraft with lots of success, would that change your mind?
You missed my point - after a diagnosis has been established for a chronic condition , and a primary treatment plan is in place, there is no reason to deny the fact that pharmacist can handle treatment with pharmacology - this is precisely our domain of practice and our primary focus of training. I said nothing about diagnosis, which I would agree is not our domain.
Regardless of perceived need for push back - this is being done successfully in states where this has already become possible due to legislation changes, with very positive outcomes associated.
The providers that are opposed to this are typically older generation providers who have issues shelving their ego and recognizing the value in others. They are being ignored. The rest of the medical community who are realizing how to effectively bring others into the fold to increase quality of care, are appreciating this and we all benefit, including patients.
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I used commercial aircraft and pilots for a reason. The training and acceptable window of risk is very different in military and non-commercial settings, as are the stakes of failure. This is the reason that commercial aviation is most often used as a comparison for health care industries and practices, as standards and risk tolerance are very similar between the two.
This is also why many things that are allowed in the military do not transfer to the civilian arena without extra training or a complete retraining regimen.
I think this kind of goes back to the fallacy that meds are things to be managed separately from the rest of patient care and the common belief that primary care is easy. If you're basically just making the argument that it is algorithmic and can easily be managed from that perspective without any diagnostic factors involved, why not just use AI and skip pharmacists entirely?
Looks like you got your mind made up - when it comes to voting season make sure you vote for a candidate that would like to limit the role of pharmacists in return for lobbying money.
This is 100% your right and I support your voice in our system of democracy.
Just 3 days ago, I spoke with my state senator in person about this very issue and I know I am not the only one. She is a senator in a state that voted to allow access to pharmacist to prescribe and bill the state for the service. Slowly but surely this will likely change in more and more states.
With that said - I maintain my position that I, myself, and many of my colleagues have provided healthcare at the same level as an NP/PA, in the setting where a chronic conditions have been established, with nothing but typical/positive outcomes associated.
Oh and - there is certainly nothing easy about it.
Pharmacotherapy is not the only facet of management in chronic conditions. And I have a CPP embedded in my resident clinic who I value, personally like, and bring in to co-visit when needed. Like teaching my newly diagnosed type 1 diabetic how to use insulin at home. Or my migraine patient how to use and self administer emgality. This gives them more dedicated instruction from a pharmacist for success, and I can go on to the next patient. But I definitely wouldn’t just diagnosis a condition and then hand them off to her never to be seen again.
Even though it seems other CPPs in my organization that dip into my patient charts uninvited, unsolicited, and without even notifying me, to look for quality metrics do know other things that should be done around a condition. Example: the nice chart review they left saying my DM patient was delinquent in microalbuminuria screening. This despite the fact it is well documented in his chart in both his chronic conditions and my office visit notes that he is esrd on dialysis, listed for renal transplant, and has been anuric for years. But sure thanks for dipping in his chart unsolicited and leaving a scathing note that his microalbumin screening was overdue.
I suppose this is a good example of ego and/or someone who adds a flare of drama to a simple note which may have only been intended as a friendly double check. You are not the gatekeeper of a patient chart and the current model of most healthcare entities is to form consensus decisions with input from an interdisciplinary team. This approach is hard for some, especially when they read text with a certain dramatic tone.
I would be super curious to see what exactly was, “scathing” about the note. We diminish the value of others by saying thing like, “they dipped into a chart unsolicited and left a scathing note”. The reality of the situation is, I’m sure, very different and far less intentional.
Should we keep posting and rolling our eyes at each other via emojis? Seems dramatic to me. Are you a little dramatic in nature?
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How is it a “consensus decision from a multidisciplinary team” to just leave a random note on a patient you never met, that their physician who is their primary care provider sees 3 months later when opening their chart to chart prep for an appointment? That’s the opposite. That’s one random pharmacist going rogue but not even bothering to read their chart.
No thank you for your multidisciplinary (single sided) input but I won’t be checking microalbumin on the anuric patient with esrd on dialysis.
Yes, you can handle the pharmacology. No question. But that's only one part of it.
For diabetic patients, are you going to refer them to ophthalmology or do their regular foot exams? If they start having epigastric pain after starting their Rybelsus, are.you going to examine them to see if it's just the usual GI symptoms or if it's pancreatitis?
And even if we ignore all of that (which we likely could by upping pharmacy training just a bit), what's the advantage to me the PCP, the patient, and cost wise or having you do this versus me doing this? I'm hearing that you can do this but I haven't seen anyone explain what the concrete benefits to doing so are?
I would have to agree with you about your position on this patient. All I am saying is - I am positive that we will all be in the situation (including you) where we do not appear to be the smartest in the moment. We have all been there and anyone who thinks they are above that has some real problems and will end up hurting someone.
It is up to us as to whether or not we afford that person the compassion and respect that they deserve to not imply that the work that they do is worthless and the way that they communicate this work is in a “scathing” or otherwise aggressive and inappropriate way. This is on you to find the value in others and to maximize their potential. It is very unfortunate that we do this to each other
I'm not being facetious- what is the harm of a pharmacist screening and treating someone's COVID with Paxlovid given they don't have alarm symptoms, complicating co-morbidities or interacting drugs, and are given strict precautions on when to see their provider or go to the ER (yes, this is not an exhaustive list...).
Where is the outrage that the law currently allows me to recommend they take some ibuprofen and Mucinex to treat their symptoms?
Given that the average COVID+ American meets criteria for antiviral treatment, I'd argue the benefits of earlier treatment and access outweigh the risks of mismanagement that are inherent with any change to the status quo. As a pharmacist in the inpatient setting, I'm done with being the dumping ground for things that could have proactively been triaged this pandemic.
I don't disagree most wouldn't want this added responsibility, but the same was said about giving vaccinations a decade ago.
Thanks for this - and I appreciate that you have always been a great participant in our forum. I have never sensed that you have thumbed your nose at us in any of your posts. We’re you a pharmacist in a previous life or something?
To answer your question - the advantage to having qualified pharmacist do this is to ease the burden on the system. It’s the same exact concept as a pa/np minus the diagnosis portion. And the truth is not everyone needs diagnosis at the time. I work part time (I have a full time gig in nursing homes) in a team with 1 physician medical director, 1 psychiatrist, and several NP/PA in a hospital setting. The heavy lifting with diagnosis is done and the “maintenance treatment” is taken over by mid levels. There are always enough of us in the team that are present where if you need Someone to step in for diagnosis they are there and can do that.
I have billed countless hours helping patients adjust and manage their insulin. I have also billed many hours on the more simple adjustments like blood pressure medications, etc. You, as a physician, are very busy and honestly we need more of you to see more patients. We have found that your time is better spent elsewhere than the patient who comes in and says, my home BP measurements are bordering a systolic of 100 and needs a simple adjustment of lisinopril. Or the patient getting SoB and bradycardia with their Beta blocker.
There is plenty of value here, I could go on for a while but I don’t want to leave a wall of text.
Gotta wonder with pharmacists already prescribing antivirals that the wheels are already being set in motion for treatment after testing with other medications for other tests.
I saw the writing on the wall when I had to get an NPI number 18 months ago that was mandatory so corporate could care less about risk if it's not on them. Also didn't get any Xtra $$$ out of that which still makes me sour.
I think the toothpaste has already partly left the tube
I saw the writing on the wall when I had to get an NPI number 18 months ago that was mandatory so corporate could care less about risk if it's not on them. Also didn't get any Xtra $$$ out of that which still makes me sour.
I think the toothpaste has already partly left the tube
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I guess I don't understand this example at all. Isn't this just normal pharmacotherapy? Why would anyone not appropriately manage macro and microvascular DM complications or know how to manage common and/or serious toxicities of popular drugs to treat it. I am not trying to be nick picky, dense, or snarky, but I am unclear of what is being conveyed.
In med school I was friends with a number of pharmacy students, my dad was an optometrist, and I've seen a lot of bad doctors so I've never really seen the appeal of doctors looking down on other professions as a whole. Also, non-physician healthcare people have different perspectives at times that when I'm made aware of them can make my day easier or improve things for our patients.
The insulin part resonates here. While I actually like titrating insulin in uncontrolled diabetics (getting their sugar from 300 down to 150 is one of the bigger wins I get on a regular basis), I wouldn't necessarily mind someone else doing it.
But, now that you've expanded on what you think pharmacists can add it does give me a few areas of unease. If you're doing most (all) of the medication management in chronic disease patients, what exactly is my role in this other than initial diagnosis? Am I relegated to the parts that, at present, my understanding is that pharmacists aren't as well trained for - basically exam skills? Also, I really enjoy doing the medication management. Sure its nice to make the diagnosis but for most chronic diseases that's the easy part. But figuring out the right treatment for each individual based on their unique history and tinkering with things until we get it just right - that's fun. And last, like many doctors I'm something of a control freak. I don't even let my nurses take a history or pend medication refills, I really don't like the idea of someone (anyone really) who isn't me managing my patients' problems unless its something I can't do. Now I know that's not a great reason to not love this idea, but I suspect its pretty wide spread and I'd be surprised if patients weren't receptive to that line of thinking.
Basically if you're going to be doing medication management on patients with chronic diseases, are you also going to be doing all of the other things that need to be done to appropriately manage those patients? If not, then the still need an appointment with me anyway and having 2 different people managing the same condition just from different angles will be more expensive and require more appointments from the patient. If you are, do you have the necessary training to do everything else that goes along with it. I know that y'all know medications and side effects better than I do, but do you have the training to actually make the diagnosis of those side effects. The GLP-1 GI problems are the most common that I see. Most people get at least nausea, a fair number get some abdominal pain, and a non-zero number (in my practice I see this about every 15 months or so) end up with pancreatitis. Can you diagnose the pancreatitis if they come in complaining of abdominal pain?
Thanks 👍 That's helpful, and I really appreciate you taking time to explain. Personally, I do believe recognizing the alarm symptoms and signs of acute pancreatitis (vs other GI toxicities) would be something well within the capabilities of many pharmacists. In a VA ambulatory care system, for example, I may expect it. I certainly would also expect any BCACP to do so with ease. That said, plenty wouldn't even want that responsibility. That's a good point.
I guess one follow up question is there training and/or examination would give most comfort that some of the items mentioned could be competently managed by a pharmacist? Is there some bridge to fill the "gap" that would give most comfort that some of the more routine items could be delegated. Or are most of the camp if you want to do this advanced practice become either a MD or at least mid-level PA/NP. I ask this because I have seen very similar arguments made against PAs/NPs too, so I do wonder if there is any standard pharmacists could meet short of MD/residency and possibly fellowship that would gain broad acceptance.
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You'll never get 100% acceptance. There's still ophthalmologists that think optometrists are unsafe for anything other than glasses/contacts. Plenty of physicians think NPs/PAs are dangerous and poorly trained.
What you'd need to do is set up some kind of training program that does a decent job at teaching y'all the areas you don't really hit in pharmacy school. Maybe a 1 year "Clinical Pharmacist" residency or something. Make sure it actually does prepare you well. Then go out and do a good job. The more physicians you work with who come to trust your abilities the easier it will be as time goes on as more and more of us trust you and see the value in what you do.
This is pretty much how I feel about it. The training is the issue. Put in 2,000 clinical hours over a year like a PA and I would think the missing skills could be built to a level that would allow for independent practice. Also some changes to the base pharmacy curriculum to really focus on diagnosis and management without extending the overall length of training.
I just want to be able to make minor changes in therapy in certain cases. Say the insurance covers Symbicort and not Advair HFA. Physician writes for Advair HFA. Why can't I just change the damned thing myself?
Just let me have that.
Just let me have that.
I already do that **** and note that the doctor approved it. Ain't nobody have time to be calling doctors for formulary issues. Then I send a fax to the doctor saying "hey I changed it to this".
This is how I did it for so long. Then, I promise this will happen when you work high volume, you will inevitably get the guy who comes in an throws a massive fit saying that you almost killed him because you changed his Proair to Ventolin and he had an asthma attack. Then, of course, they will call their doctors office who then does not want to touch the situation with a 10 foot pole and they will be happy to throw you under the bus saying, “oh but we wrote for Proair” and they will commiserate with the patient saying that they are blameless and the pharmacy should not have put them at risk by switching albuterol to albuterol. Then you will be threatened to be sued and a video of your conversation will be posted on Twitter for the world to see. Then all the Twitter comments will roll in saying something like - “omg!! The pharmacist is not a doctor! They have no right to switch drugs! You should sue them!!”. If you are unlucky enough, the story will catch national attention and Anderson Cooper on CNN will be presenting the story of you switching Proair to Ventilin to the whole world and how you overstepped your boundaries as a pharmacist and almost killed someone….
You think this can’t happen?? Think again…. Maybe the Anderson cooper part is a bit much but maybe a lesser news anchor..
I swear - it’s damned if you do, damned if you don’t. We can only hope that luck is in our favor to avoid these situations.
Best way to prevent this, as soon as you make the change, send an e-refill request that way they send back an electronic prescription for the thing that is being switched to, and then there is your documentation.
I really like this suggestion - however, we are crossing our fingers hoping the provider will respond with a valid Rx before the patient comes in to explode.
Still a gamble
This is fair enough that this model may not work for you and that your style of practice would not be a good fit.
However, there are many physicians that are more than happy to fit this model as what they really want to do is instill a team of competent/trusted providers who work under their banner to see many patients. These patients are typically the less complex patients. The providers involvement is much less than yours - and they are always just a call/text/zoom away.
I get the impression you pay way more attention to meds than any of the physicians I work with, lol. But kudos for that!
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deleted941485
Your paymasters don't care if its a half assed job. You can bill Medicare for it without an MD/PA/DNP writing a script r providing an assessment... and that's all that matters. The bottom line is pharmacists are being pushed out by automation and now they need a new role or they'll be on the breadlines so they came up with this niche to fill.
Honestly, the alphabet soup of so called providers coupled with the low pay and the hours are the reason nobody pursues primary care anymore as an MD anymore. The concept of "team" care is nonsense physicians played that game with the NPs and PAs and got burned. If you needed any reminder of how this ends just look at Anesthesia. It is clearly not a team sport, its just a shoehorn. Care team is a just a stepping stone to bigger and better things for MLPs and ultimately power. Oh supervising physicians...please. Pharmacists are not clinicians. following the hospital team around the ICU every few days to tell us about the vanc trough or the EID for aminoglycosides isn't medicine.
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deleted885753
Plenty of MDs pursue primacy care and they make great money. And anesthesia isn’t starving.. Job market for primary care physicians and anesthesiologists is as good as it has ever been.. this post is garbage..
I have read enough of @VA Hopeful Dr ‘s post and regularly visit anesthesia forum to know this.
Yes - thank you for telling us how it is in such a precise and authoritarian way - you definitely know how to just lay it out for us.
You are definitely the smartest person in the room.
There is certainly not an issue of ego here.
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deleted885753
Meh.. egos are big in medicine since everyone is supposedly educated and “smart”.
I believe OP is a Rad Onc which is ironic because their specialty is suffering from the same fate as pharmacy; once highly competitive field getting destroyed by oversupply of residents. I browse their forum once in a while. Their twitter drama is quite entertaining as opposed to a dead forum like pharmacy 🙂
I believe OP is a Rad Onc which is ironic because their specialty is suffering from the same fate as pharmacy; once highly competitive field getting destroyed by oversupply of residents. I browse their forum once in a while. Their twitter drama is quite entertaining as opposed to a dead forum like pharmacy 🙂
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Thankfully his/her thoughts about the state of pharmacy/pharmacists matter just as much as pharmacists thoughts on the state of medicine/physicians. Really not worth the time to engage unhelpful/uninformed/ill-mannered/utterly unimportant trolls.
You are right/correct.. 😁
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deleted941485
If there’s an ego issue, it’s coming from your end. The sheer arrogance to believe that pharmacy training alone allows you to treat these people appropriately (I’m sorry in a team like setting) or even puts you in the same category as the as the army of MLPs already out there fighting for independent practice is impressive and outmatched only by this country’s contempt for expertise and addiction to cheap labor.
Fortunately - your opinion really does not matter. Neither does mine really…
You speak of arrogance like It would not apply to you.
You should just keep your little negative Nancy crap to yourself. Or, at least, save your crying for your own forum. You don’t know anything - and, in real life, I will keep ignoring folks like you because you really don’t matter.
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Lawyer here. I would sue the pharmacist and the pharmacy. As would every other lawyer. The pharmacist might be indemnified by the pharmacy, but their name is still going on the papers, and they’re still going to need a lawyer. Depending on the way negotiations go, they might end up paying too.
Agreed - and I believe you - I have never seen a lawyer pass up on the opportunity to sue as many people as absolutely possible.
Is there ever a good reason to not do so, unless they are judgment proof?
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That's easy: I'd just literally never prescribe Tamiflu because it's trash. Lol
And your satisfaction scores just tanked
I just don't understand why the organizations and legislators can't get it through their head what we actually need on the ground. We don't need the authority to do more work than we have time for. We do need a way to get reimbursed for the cognitive work we are actually doing.
Our entire department's budget is based on dispenses, so every time I recommend to d/c a med I am technically hurting our budget. I can't convince our hospital to take cost savings into account so I would love to be able to put an actual number to some of our cognitive services other than just making it "better" for the physicians and nurses.
I fully believe that there should be both reimbursement legislation and legislation that formalizes authority that usually falls under collaborative practice agreements. Pharmacists can absolutely function as physician extenders in many situations where drug monitoring and management is needed more often than management of other parts of a disease. CPA's are a great option where these exist but many require more red tape than is required.
Our entire department's budget is based on dispenses, so every time I recommend to d/c a med I am technically hurting our budget. I can't convince our hospital to take cost savings into account so I would love to be able to put an actual number to some of our cognitive services other than just making it "better" for the physicians and nurses.
I fully believe that there should be both reimbursement legislation and legislation that formalizes authority that usually falls under collaborative practice agreements. Pharmacists can absolutely function as physician extenders in many situations where drug monitoring and management is needed more often than management of other parts of a disease. CPA's are a great option where these exist but many require more red tape than is required.
There isn’t, even if they are judgment proof. If the suit doesn’t include the pharmacist then the pharmacy can use that as a sort of defense (really just a delay tactic). Wasn’t us, the pharmacist was acting on their own. So even if it’s some kid out of school with more debt than anything resembling an asset, they still need to be included in order to tie in the pharmacy and the pharmacist together.
I’m done practicing and I never really liked the idea of suing doctors/nurses/pharmacists, but when a medical professional does something so dumb it verges on intentional, they bring it upon themselves. Pharmacists prescribing medications without doing histories, exams, follow-ups, and without having the training to do those things— well that’s pretty darn close to intentional.
Objection your honor!!
Not one pharmacist here said they wanted to prescribe anything without doing histories, exams, follow ups, or lacking training.
The fact that we're arguing with physicians over whether or not we should be paid for services that our state has already licensed us to perform just goes to show you how our industry is on the decline. Scope of practice, adequate training, etc. It's all inappropriate nonsense. We deserve to get paid for doing our damn job.
Tele doc looks at my summary I summited online, looks at pictures of my throat ( they have option either on the phone or video chat with me). Then decides that I have strep and prescribes me zpak. If my symptoms would get worse in a couple days, call 911. No lab drawn, no physical examination. IMO, that also can be done by an Rph at the pharmacy.
Of course, i wouldn't want to step into that mine field of possible-getting-sued and more stress with same pay. Just like doctor won't want to step out to do all the dispensing, PA craps, customer services like can you buy me milk or condoms from a drive through customer...etc for the same pay, will ya?
Of course, i wouldn't want to step into that mine field of possible-getting-sued and more stress with same pay. Just like doctor won't want to step out to do all the dispensing, PA craps, customer services like can you buy me milk or condoms from a drive through customer...etc for the same pay, will ya?
Chocolate milk and condoms would be a waaaay better combo. And if someone at the drive through told me they needed chocolate milk and condoms, I would turn around and yell to the technician, “Hey, can you grab this guy some chocolate milk and condoms?! He is in a hurry!”
But yea - again, it goes to my point that 90% of the resistance to pharmacists from physicians is entirely ego-driven. There are a few reasonable arguments about diagnostic training but that is it - anything else is just speculative, territorial, ego driven nonsense. I am fortunate to work with very gracious physicians in my work and this attitude that you see above is entirely non-existent. We are simply doing the work that we are all fully qualified to accomplish.
These goofballs that take time out of their day to make a one-time appearance in our space to do nothing more than, “pull rank” can go fly a kite.
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100%. Healthcare is full of boomers.
If the companies were run by tech industry people, they'd definitely take cost savings into account as an impact
That's bad medicine.
Well, would doctor talk over the phone with patients that has stuffy nose, sore throat, head-ache and tell them to get some benadryl, Mucinex DM all day long without getting paid? If so, leave their clinic number up here. Will gladly tell patient to call that number to get a good medicine practice. Or they want patient to come in and then prescribe the same thing with zyrtect, flonase, Mucinex and then charge patients?
I thought Dr nowaday complains about work loads and metrics too like how long they should see a patient etc. If RPh can decrease the work loads for docs by taking care of those minor, acute sickness, that would be wonderful for the healthcare, no?
