PHYSICIANS & PHARMACISTS…PROFESSIONAL EQUALS?

We often hear about the need for more professional collaboration between pharmacists and physicians.   How realistic is this really, when pharmacists often position their raison d’etre as to be second guessing a physician’s direction?   What does it mean to be a “medication expert” and to have the duty of determining if a particular medication is “therapeutically appropriate” when pharmacists most often have no medical data on the patient?   How many physicians welcome pharmacists performing this self-created second guessing role?

All this may be standard procedure in a hospital setting, where pharmacy as a profession not only still exists, it’s thriving.  Too bad all those PharmDs that Academia is churning out can’t get jobs in hospitals and really put to work that 6 years of education, instead of getting stuck in a 10’ by 20’ cubicle in a food/drug combo bagging pizzas and toilet paper, or surfing the internet for something to do.

How does society value a particular profession, and what is society prepared to pay for a service given?  How does society perceive the value of a given function?

Let’s have a brief look at current negotiations which are about to begin between the Ontario Medical Association (OMA) and the Ontario government to hammer out an agreement…the biggest labour contract in North America.

Physicians have seen their fees cut by 7 % during the time they have been without a contract.  The docs want all this money back.  Millions & millions & millions.

Ontario docs bill on average $375,000 annually before overheads.  That’s an average, which needs to take into account part time docs, and female docs who insist on restricted hours, which means many docs are billing well over half a million a year to the Ontario government.

The docs want a 4.26% fee increase effective back to April 1, 2017.  Back pay.  In addition to this, the docs are looking for annual increases which amount to a further 15% increase by 2021, three years from now.  Docs work hard and it takes a lot of time and money to get a medical degree, so why not?  The docs want no cap on the physician services budget.  Limitless physician services is what physicians want, and they believe their value is there. Great if they can get it.

Of course the docs want to preserve the present fee for service system…the more services they perform, the more money they make, even though it is commonly known that this is a highly inefficient costly system which emphasizes the provision of more services while less effort is given to the prevention side.  No money in it.

The government is offering 3% over four years and no back pay.  It also wants to cut back money to those docs billing over one and two million dollars.  Yes…that’s 2 million in billings for just one doc.  Well let’s see how all this is going to pan out.  My hunch is that the docs won’t get all they want, but they will make good headway in recovering their position.

The reasons for this are simple.  Docs have a strong bargaining position, and though they do not always agree that their own association, the  OMA, does the best job possible in getting them the best deal, docs know the government will eventually cave in because the public will not tolerate any interruption in physician services.   The docs’ hands are firmly grasped on the handle of the vice.

Compare this to pharmacists for a moment.  Not that long ago, a pharmacist in a community setting in Ontario was “valued” at about $60.00 per hour in the Greater Toronto Area (GTA)…about $120,000 per annum  Today that number is maybe $38.00 representing a decrease of at least 35% over the past 5 years.  Coincidentally, the business of pharmacy has been hit at least three times from different angles.

Big Pharmacy Retail (BPR) can absorb these hits (though not happily) by selling more stuff, any stuff, and cutting costs (especially pharmacist compensation) to make up for the losses.  So pharmacists, who are essentially unprotected/unrepresented retail employees, just get nailed.  Hence the 35% decrease.  This compensation decrease is not government mandated, it’s commercially driven and to be expected in a highly competitive retail environment.  One wonders if the government even knows (or cares) about the financial impact its policies have had on individual pharmacist practitioners.  When government thinks of pharmacy, it thinks Costco, Walmart, Loblaw, Shoppers Drug Mart, Pharma Plus, Sobeys, and Metro etc.   Big Business, not pharmacy practitioners.   Which advocacy group zeros in exclusively on the financial plight of individual pharmacist practitioners?  It doesn’t exist.

Back to our physician colleagues, the ones taking home a minimum of a quarter million a year after expenses (and often much more).  How do we square pharmacists as professional equals to physicians when docs are valued at a multiple of 6 or 7 times over pharmacists?  This is a tough one.

Whenever pharmacists are portrayed on television in one of the many investigative journalism exposes lately (usually about abuse of the system by pharmacy) the camera zooms in on the little blue tray and the pharmacist is seen counting pills.  Well what’s that worth? … a machine can do that easily.

During the recent devastating Fifth Estate piece about Costco and kickbacks (sorry, rebates) not a single pharmacist was interviewed.  Plenty of great shots of the Ottawa professor who described the whole pharmacy landscape as corrupt and the Ontario College of Pharmacists (OCP) as weak & ineffective.   The OCP building was seen in the background as the CBC journalist and whistleblower hacked pharmacy to bits on the sidewalk; no one came out of the OCP building to defend or represent pharmacists.

The real hero of the CBC piece was a physician at St Michael’s Hospital in Toronto, who through personal efforts managed somehow to get medication to 400 patients who had no coverage.  Get the Super Hero analogy with pharmacy described as the dark side?

Docs are always portrayed as kindly counselors with a stethoscope wrapped around their neck patiently listening to their patients with only the patient’s welfare in mind.  That, or they are doing brain surgery.

It begs the question.  Why spend 6 years earning a pharmacy degree to earn one seventh of what a GP earns after spending years of study at an equal level of academic challenge?  Why, when the value is clearly not recognized?

And how do our various pharmacy associations respond to this terrible image problem?  The latest is the suggestion that Pharmacist Awareness Month (PAM) be changed to Pharmacy Awareness Month to “recognize the whole pharmacy team”.  Is this an effort to be inclusive and politically correct?  Dilute the pharmacist?  Is this a move in the right direction for an already besieged ‘profession’?

There’s a whole lot of difference between the OMA and the OPA, and it goes a lot much further than a change in the middle letter from an ‘M’ to a ‘P’.  The image of pharmacy today cannot get much lower, hence its value continues to go down with it.

Pharmacists deserve a great deal more from their leadership whether academic, association, or regulatory.

 

6 thoughts on “PHYSICIANS & PHARMACISTS…PROFESSIONAL EQUALS?

  1. re. “What does it mean to be a “medication expert” and to have the duty of determining if a particular medication is “therapeutically appropriate” when pharmacists most often have no medical data on the patient?”, in Ontario, access to the EHR is being rolled out to pharmacies and pharmacists as we speak. That should help with that issue in the community setting.

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    • In these days of Facebook and Cambridge Analytics, I wonder how comfortable people are going to feel when they discover that their personal health information is going to go to Loblaw and Shoppers Drug Mart, or Sobeys, or Walmart etc Together with all of that information already on them in those Optimum cards. That’s a lot of very powerful personal information. I am betting many people do not know this is happening and when they do find out, there will be a back lash.

      I for one would never want any information about me passed along to BPR and I have already taken steps to ensure this will never happen. But it’s a default system. You are in unless you take yourself out. Deemed consent is what they call it.

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  2. Well,

    1) the GTA physician was taking blood pressure wrong – who the heck takes blood pressure OVER clothes? I wouldn’t want someone who messes up something basic to be my physician.

    2) Years of education shouldn’t be our arguing point. You have PhDs in medieval art history that have spent how many years studying their craft and only a very small handful have decent jobs. Just because pharmacists have more YEARS education doesn’t necessarily mean quality, translatable to patient care, education. How would knowing the pKa of a drug and Henderson-Hasselbalch equation really be useful in primary care? Most pharmacists say that their best asset is ‘accessibility’ and ‘spending time with patients’ but let’s be honest – a privately paid nurse could do that. And there are pharmacies who employ LPNs to administer vaccines BUT bill it under their own license to provincial plans. So these pharmacists aren’t even using their skills but just milking it. Which leads to point three:

    3) The ONLY expertise/ skill that a physician can’t have that pharmacists can do is dispense. A physician armed with the CPS and google pretty much eliminates any ‘expertise’ a community pharmacist has. Pharmacists need to provide true value.

    This is the test of value. If a physician were to approach a pharmacist and say,

    “We are looking to create a healthcare team. We have limited funds. What value can you provide to the patient and the team? We also have ongoing audits so unless you can provide ongoing and consistent expertise we do replace people.”

    ^This is what hospital pharmacists provide – things like vancomycin dosing where no otheyr professional will touch with a ten foot pole. But what about the community pharmacist? OTC counselling? Nurses and physicians can do that. Most OTC have bad evidence, and would anyone really PAY extra for a pharmacist just to talk about cough and cold? Even patients just look it up on Google and won’t pay a pharmacist.

    4) Assessing therapeutic appropriateness…. honestly it’s patient history. Physical signs you can always ask what physician explained to them, and ask patient to bring in a copy of their labs. You can do all of this as a pharmacist.

    ^Then the question goes back to … well it’s not paid why do I do it…. and then people go….well why pay it unless you can prove it is worth it.

    It doesn’t help that pharmacists who are in a great role to do this like in Alberta haven’t shown enough value. Let me put it this way. If all but a handful of physicians were to disappear from a city there will be a terrible outcry. However if all but ONE pharmacy is left no one will care…. except maybe prices are high.

    We have no value in this volume based environment. Why are we complaining to be professional equals when…. honestly why should we? Easily replaced by machines. Physicians aren’t afraid of being replaced by machines. Certain services yes but there will always be a need for physicians. But not pharmacists.

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  3. “Pharmacists deserve a great deal more from their leadership whether academic, association, or regulatory” 100% YES.

    Great blog Bill. It’s certainly a challenge to consider what the value, if any, do pharmacists in the community bring to the table. I work at a Family Health Team (a rare position, in part because OPA doesn’t advocate for any role for pharmacists outside the four walls of a community pharmacy, and God forbid they advocate for anything other than vaccines and cannabis). The faxes we get from community pharmacists “collaborating” with docs are highly administrative, unsigned by the pharmacists, and often deferential – e.g. drug interaction identified – what do “you” (the doctor) want to do? Not as common to see a proactive expression of clinical judgement being exercised.

    I have zero faith in OPA. They seem to be referring to us these days as the “pharmacy industry” – annoys me that they don’t typically use the term “pharmacy profession” – and I agree the political correctness in not specifying pharmacists, and using a broader term is problematic. Quite frankly if BPR could get away with just using technicians- it would….. and OPA, OCP and the faculties would remain silent.

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    • Suzanne, we all knew that the ‘cottage’ of pharmacy is a piece of work. I really like your comment about,

      “The faxes we get from community pharmacists “collaborating” with docs are highly administrative, unsigned by the pharmacists, and often deferential – e.g. drug interaction identified – what do “you” (the doctor) want to do? Not as common to see a proactive expression of clinical judgement being exercised.”

      It’s true insight that the big wigs up in the cottage doesn’t understand. How are those administrative tasks beyond those of a registered technician? We are going to fail. Perhaps I’ll go be a nurse.

      Like

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