EXPANDED SCOPE OF PRACTICE? LET’S TAKE A BREATHER. billbrownblog.com April 19, 2018

“Expanded Scope of Practice” (ESP) is the current mantra for pharmacy’s salvation, constantly embraced by pharmacy regulatory bodies and pharmacy associations.  As drug costs continue to fall through the floor, and while pharmacists’ compensation continues to be tied to drug costs, ESP is seen as the answer to the survival of the profession of pharmacy.  But is it really?

First of all the term itself is misleading.  Flu shots are not an expansion of pharmacy knowledge/expertise.  Injections are a technical or nursing skill.  Secondly, diagnoses be they urinary tract infections or contraception or other so called ‘minor ailments’, all of these are not an extension of pharmacy as it is currently being taught in any of the universities in Canada today.

So the word should probably be changed from ‘expansion’ to ‘accretion’ or maybe to ‘replacement’, but this new ESP direction is not an expansion of core learned skills, it’s the assumption of skills currently held by other professions be they nursing, lab technicians, or medicine.

This then begs the questions: Do pharmacists possess the required education and/or training to perform these new duties?  Having studied for one profession based on pharmaceuticals/therapeutics primarily, do pharmacists really want to perform acts associated with other professions?  How happy are pharmacists across Canada today doing flu injections?

Another critical question is: How welcoming are other professions with this ESP development?  The following is an edited version of a letter recently published by the president of the Saskatchewan Medical Association entitled “Patients Should Be Wary of Simple Solutions”; I have a hunch it represents a large chunk of medical opinion in Canada today.


“We at the Saskatchewan Medical Association are all for improved patient access to high-quality care. Doctors don’t lack for things to do and we are happy to share duties with other professional colleagues. Unfortunately, sometimes problems that appear to be simple (read minor ailments) and easy to fix turn out to be signals of something more complex.

We have raised concerns about this new development. (read Pharmacists’ ESP) The SMA believes it is critical for patients to have what is called a medical home: a continuous source of comprehensive care, where patients have a relationship with their family physician and other providers. In such a setting, signs and symptoms of a health issue can be diagnosed and interpreted in the context of a patient’s overall life and health experience. This isn’t pop psychology or overkill — it is verified by a great deal of research. Put simply, fragmented care increases the risks of something going wrong.

Many community pharmacists practice in independent facilities (read your local food/drug combo) and may have little or no relationship with their patients’ doctors.  Will the pharmacist accept responsibility for an adverse event? Will the diagnosis and treatment automatically become part of the patient’s health record? Will the patient get conflicting advice from her doctor and her pharmacist?”


The SMA President goes on to state further observations.  When pharmacy professes that ESP will save the healthcare system big money (presumably by decreasing the number of visits to doctors’ offices) the inference must be that pharmacists will do these activities for free (not surprising if we look at historical experience).  Or will pharmacists be paid by governments but at lower fee rates?  Or will pharmacists charge patients directly for their services?  …as there is current encouragement from pharmacy associations to do.  And if pharmacists do charge patients directly for their services (because governments refuse to pay them) then doesn’t this fly in the face of free universal healthcare, the touchstone of Canadian identity and the direction of government political wind?

What about conflict of interest?  If the only way that pharmacists continue to be compensated is when they actually sell something, isn’t there a conflict of interest when the pharmacist is both the prescriber and the dispenser of medication?  Isn’t this why pharmacy and medicine were separated a thousand years ago?   Isn’t this why physicians are forbidden to own an interest in a pharmacy?  (Though many physicians do through astronomically inflated rents to pharmacists in physician owned medical buildings).

How long before some number cruncher in ‘head office’ figures out that 60% of customers coming through the door are women, and at any point in time 8% of them have a UTI?  Look forward to quotas from head office for pharmacists for the prescribing and dispensing of MacroBID.  You heard it here first.

So on the surface, although ‘expanded scope’ has a nice ring to it, there exist many pitfalls and a potential mine with further implementation.

When I discuss this issue with my physician colleagues, I invariably get the same response, which many of us have heard before:  “If you want to practice medicine, why don’t you just get a medical degree?”.

Just because pharmacy may be headed towards increasing irrelevance through automation and corporate/commercial (BPR) domination, encroaching upon the professions of nursing, lab technicians, or medicine may not be the soundest strategy for survival.




Automation, artificial intelligence, robotics, are all coming at once.  The speed is overwhelming and threatens to alter society in ways not yet fully predicted.  How will this affect pharmacy? … But more importantly, how will it affect individual pharmacists?  And a corollary question might be…What is Academia telling pharmacists re this very different fast changing world and the impact it will have on them?

In a recent piece in the Globe and Mail (from which I am borrowing heavily) on the subject of robotics in the work place, a striking example is given of London’s taxis, of which there are 20,000 weaving through the city daily. Getting a licence means passing the ‘Knowledge Test’ which involves memorizing thousands of street names, landmarks and routes. Passing the Knowledge Test is difficult & key to becoming a licensed cab driver.

And then along comes Uber.

No Uber driver ever takes the Knowledge Test because Uber’s mobile app is displayed on a driver’s smartphone which provides turn-by-turn instructions on where to pick riders up and where to drop them off. Street names, landmarks and routes are all laid out in detail, and the driver simply follows the instructions.

So when it comes to driving riders around, the app – not the driver, does the heavy work.

Therein lies the challenge. The app circumvents the need for knowledge of London’s streets: knowledge that riders historically paid a premium for. The result is a lower qualification standard for would-be taxi drivers; one that ultimately drives down wages, because as the job becomes more simple, it means that anyone can do it, so why should anyone incur the cost of a higher paid individual when this is unnecessary.

Anyone who performs tasks which are considered repetitive, routine and predictable is vulnerable to being replaced by a machine. The Industrial Revolution déjà vu all over again.  This is the type of work machines do well without tiring or faltering and more importantly, they do not demand any compensation or lunch breaks.  No washroom breaks either.  Sound familiar?

Many venerable professions, once thought to be untouchable, are at risk for the same reasons.  Dermatology and radiology are prime targets.  A computer can memorize millions of images of moles or MRIs and recall them in a nano-second and compare these to the image at the moment.  Plus the computer can be anywhere in the world including a low cost country like India.  Ever wonder why there are so many cosmetic skin therapy shops popping up all over?  The new market is more cosmetology and less skin disease.

Any activity which is based on accumulated data, or an activity which is repetitive and subject to an algorithmic formula is vulnerable to digital technology applications and artificial intelligence… which means the machines can actually learn from the experience they gain.

Now go back to the London taxi drivers and substitute ‘pharmacists’ into the example in place of ‘drivers’, and ‘pharmacy’ instead of ‘London’ and ‘drugs’ instead of ‘streets”.  Are we not seeing the effects of technology?  Script filling machines, computers which identify interactions and contraindications instantaneously, face recognition technology, e-prescribing etc.

Pharmacy education continues to produce graduates who in 85% of cases enter what is referred to as ‘community pharmacy’, meaning they end up working for Big Pharmacy Retail (BPR) and stand all day in a 10’ by 20’ cubicle staring into space or checking prescriptions till they get cross eyed.  A good deal of time is also spent bagging pizzas and toilet tissue, as the customer does not want to check out at the front cash where the lines are long.  The customer is always right.

How many times can you say, ‘Take with food’, or repeat instructions already printed on the label, or recommend a useless cough syrup, before delusion and apathy set in?  About 6 months after graduation, on average.

We are already witnessing Big Pharmacy Business (BPR) instituting two policies which are having a direct effect on employee pharmacists.  BPR is replacing more mature experienced pharmacists with freshly minted graduates (or IPGs) at significantly lower pay scales (so much for appreciation for loyalty and years of dedication).  Secondly the use of more pharmacy assistants (maybe also some so called pharmacy technicians) is becoming more prevalent.  Anything to save a buck in a razor thin margin business activity, namely dispensing drugs.  Still lots of money still to be made selling all the other stuff of course: cough syrups, fat flushes, homeopathy, useless vitamins etc. and we must not forget the pizzas, candy and pop.

So what has pharmacy Academia done in the face of this reality?  First Academia ignores reality, and then, if all that data isn’t enough, it pours on more data and forces all pharmacists to become PharmDs.  So now we are seeing PharmDs sitting in those 10’ by 20’ cubicles making $38.00 an hour, agonizing about how they are ever going to pay that 120K (or more) student loan, and wondering where it all went so wrong.

A Pharmacy Degree does not have to be a life sentence.  Change is happening quickly.  Pharmacists are already getting caught in the cross fire.  Plunging compensation, under employment, and even unemployment are now becoming the norm.  Meanwhile hungry governments keep picking away at pharmacy’s flesh.

The answers are: not clear.  But we can start with: adapt, innovate and be prepared to take risks & to change one’s personal environment.   If pharmacists continue to hope for the best and to rely on so called ‘pharmacy leaders’ to lead them out of the desert, doom is the inevitable conclusion.  If pharmacists leave their fate in the hands of others, the future is predictable.  Not good.

Every pharmacist must take a hold of his/her own destiny and shape his/her future with hope, job satisfaction and future security, and this just might be outside fast disappearing  traditional retail pharmacy.

It’s never too late to reach out for what you want in life, and a pharmacy degree does not have to anchor you to the sea floor.