THE PROOF IS IN THE PUDDING

As part of the process of renewing one’s annual pharmacist registration (in Ontario at least), it is now necessary to pledge that one has read the Code of Ethics and that one fully understands the Standards of Practice.  This would seem a minimum expectation.  In the language of these documents and videos, as well as in other publications, and continuing education materials which emanate from these regulatory bodies, pharmacy associations and academia, much is made of how pharmacists are now the “medication experts”, and that it is now not only necessary to correctly/accurately dispense medications, it is the legal obligation of the pharmacist to ensure the “therapeutic appropriateness” of the medication taking into account the patient’s allergies, drug interactions, health status, lab results etc.  The pharmacist represents the moment of truth, and saves the day by rescuing the patient from an otherwise preventable error…a lifesaving act in some cases.  Why are there no TV shows about brave life- saving pharmacists?   Grey’s Anatomy move over for Have Spatula, Will Travel.

This is all great stuff in vitro, but I wonder how practical it is in vivo.

Taking it from the top.  The patient visits the physician who, using his/her own expert knowledge, plus a plethora of available testing modalities (lab tests, imaging, etc.), makes a diagnosis.  In the majority of cases the physician prescribes medications of some kind specifying the molecule, strength, directions, repeatability etc.  But, I guess the assumption must be that the physician does not have the required level of expertise in medications; he/she is not the “medication expert” that the pharmacist is, and that the physician is relying on the pharmacist to serve the purpose of ensuring the therapeutic appropriateness of his prescribing.   I wonder how many physicians would agree with this assumption?

Imagine if the aerospace industry was structured this way.  One person designs the plane, another one builds it, and when it is all ready to fly the last person looks and finds all of the problems, fixes them, and prevents catastrophe.  In this analogy the last person is the pharmacist.

In a closed system, like in a hospital, this system might work.  All the medical records, all the tests and images are all there in one place.  As importantly, the patient is fixed in one place and follows directions to the letter from the healthcare team.  Adherence is not a problem.  Head Nurse ensures this, and the hospital pharmacist is in constant touch with all elements of the patient’s medication needs in context, and with all of the other elements of the patient therapy.

Flash forward to the retail pharmacy marketplace.   The patient/customer is constantly barraged with messages to switch pharmacies.  Loyalty points are a big draw.  Then there are discounted dispensing fees.  Shoppers Drug Mart is now advertising on TV that in the interest of patient care and concern, it does not charge the $2.00 co-pay…many prescriptions are free at SDM for eligible patients.  “It’s easy to switch” say Sobeys.  And you know what?  Many patients do switch, and switch many times depending on the incentive, who is giving it, and where it is.

Costco has a dispensing fee of around $4.00.  Many patients have 8 prescriptions or more.  Do the math.  Instead of a $12.00 fee (a saving of $8.00 per Rx), this represents a saving of $64.00.  You bet this patient will switch.  I love going to Costco and invariably I visit the pharmacy.  I am always astonished to see a line- up of patients 8 or 10 people deep, waiting patiently to hand in their Rxs to a pharmacy assistant.  No wonder…look at the savings!

When a patient presents a prescription at a pharmacy counter, the Rx must indicate the patient’s name and address.  Usually also indicated is the DOB and possibly an OHIP number.  If the patient is paying cash, the patient is not obliged to produce any other information if the Rx is not a narcotic or controlled drug, and often the patient chooses not to do so.  The pharmacy assistant asks if there are any drug allergies and that’s about it, as far as compulsory information goes.  Pretty limited.

Let’s say we are talking about one of these really busy Big Box stores doing 600 Rxs per day with one pharmacist (doing a 12 hour shift) and several assistants and maybe one technician.  In the meantime there’s a sign stating “injections, no waiting” and whole families are now waiting for the pharmacist to give them their shots (soon to include a whole bunch more injections, thanks in Ontario to OPA’s successful increase in qualified injections).  The prescription is for an antibiotic and an analgesic.  The pharmacist now needs to determine the “therapeutic appropriateness” of these medications for this patient whom he has never met before, knows nothing about, and frankly the patient is in a real hurry after waiting in line for the last 15 minutes.   Maybe if the pharmacist was Wonder Woman or Superman with super powers this might be possible.

Maybe it’s OK to reach for certain goals in life, even if they are not attainable; the striving is important and performance is kept at its peak.  Maybe it’s OK to use words like “therapeutic appropriateness” if it makes people feel good, and at least people put in the required effort whenever possible.  But let’s not kid ourselves, nor our pharmacy students, that this is how their pharmacy career is going to go.  Leave it to the academics and the other association and regulatory boffos to invent fancy phrases in their ivory towers, but in the real world you have to know what it really takes to stay alive.

I am resigned to receiving a lot of poison pen letters from many starched white coated pharmacists who will profess that I am a nasty, cynical, out of touch fossil.  But the other 95% will breathe a sigh and will be in agreement.

The problem is not the pharmacy profession or the commercial environment that has it by the throat; the problem is in the resignation and delusion that the majority of pharmacists sentence themselves to.

Anyhow, maybe once in a while something really terrific happens, in which case you can send a Valentine.

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