A concerning report

pharmacist phone query script refuse supply

The recent methotrexate inquest indicates a real need for universities to provide assertiveness training during pharmacy courses, writes Jeff Lerner

AJP’s report, “A ‘needless and entirely preventable’ death: Coroner” is extremely concerning.

I believe that it indicates a real need for universities to provide assertiveness training during the pharmacy course. It might have helped to avoid the tragic outcome of this case.

Several years ago a young pharmacist contributor to Auspharmlist (now AJP.com.au) described an interaction with a doctor in which he (the pharmacist) was intimidated and over-ruled. I could relate to that because I had experienced a doctor saying to me: “Don’t you dare question my prescribing.”

The pharmacist ended his fairly long post with: “Now, can anyone tell me what to do? I decided not to call that doctor again but that is not the best solution because this may put a patient’s life in danger.”

Below is an extract from my response to his post:

[Name], you’re right – that’s not the best solution. Not even a viable option. You really can’t afford to say that you will never call him again. How will you sort out any future Rx problems? I doubt that your Pharmacy Board or PDL would support you in doing that, but I believe they would support and advise you if you ask for help. However, there are some things you can try first (which may not be easy from the position of a trainee or newly qualified).

I’ve been a pharmacist for a long time. When I was younger I sometimes had the same sort of difficulties that you mention when dealing with doctors, but then realised that a significant part of the problem lies with ourselves and our approach. I reached this conclusion by doing mental replays of interactions I’d had with doctors, and by listening to other pharmacists when they phoned doctors.

If you are timid, hesitant, nervous, over-apologetic, consider yourself subservient, and anticipate problems then you will probably have problems; this is known as self-fulfilling prophecy. What’s needed is to be polite and courteous yet assertive, know what you’re talking about, and get to the point without wasting time.

Here is a typical opening assembled from many actual phone calls that I’ve heard over the years:

“Oh, hello Dr Whatever. This is Jenny from xxxx chemists. How are you today? Thanks for taking my call. I’m really sorry to bother you, but I’ve got your script here for Ben Dover and the computer is telling me there’s an interaction with other medication.”

There are several things wrong with this:

(1) Don’t waste time enquiring about his (or her) health or expressing gratitude that you’ve been put through. He’s probably busy (as are you). Don’t waffle. Get to the point.

(2) Don’t apologise for doing your job diligently in order to protect your mutual patient, especially if there’s something clearly careless or deficient about his prescribing.

(3) Always introduce yourself by full name, never by given name only (unless it’s a doctor you already know well) and state that you are a pharmacist. Some doctors are happy to use first names, others prefer a more formal approach. If you state your first name only, then that’s all he can call you.

I say: “Good morning. This is Jeff Lerner – I’m a pharmacist at xxxx pharmacy. I need to briefly discuss Anna Filaxis with you.”

If he addresses me as ‘Mr Lerner’ then I’d call him ‘Dr Whatever’, but if he calls me by first name then I do likewise. If you use his title but he calls you by your given name then it puts you at an immediate psychological disadvantage. This might sound trivial, but it’s certainly not; it helps to establish that you are not subservient but that you consider yourself his equal.

(4) If your query is about a possible adverse interaction then be sure to have all the facts ready when you phone: i.e. mechanism of action, likelihood of occurrence, potential consequences, and suggested action to be taken. Don’t quote your computer; offer references to reputable sources of information. I have a letter from a doctor stating that he was happy to be phoned about any queries because he appreciated that, more than once, we had saved him and his patients from a possible serious outcome.

A few examples will show what can be achieved:

(a) At one large pharmacy some of the younger female pharmacists would not phone a particular prescriber but used to ask me to make the call. I once had to explain to a patient that I could not dispense his Rx because of an anomaly which the doctor refused to discuss. The patient returned to the surgery, demanded and got a refund of the consultation fee, and went to a different practice. The doctor called me to apologise.

(b) A customer who was a member of a very prominent Melbourne family wanted to obtain a S4 drug on the promise of a script to follow (note I’m not calling it an ‘owing script’ as that’s something different). For various reasons I was not willing to supply and, after some argument, he left.

Later that evening his doctor phoned to rebuke me, loudly and aggressively, for not giving the man what he wanted. I told him that I was happy to discuss this provided that he lowered his voice and did not speak to me as if I was his employee. He continued to rant so I told him that the conversation was over and I hung up the phone. He called me back later and apologised.

(c) One doctor had the worst writing I’ve ever seen – every Rx totally illegible. Always had to waste lots of time phoning him. When I asked him to use block capitals he took offence and said that he’d report me to the Pharmacy Board. I gave him the Board’s address to send his complaint, and then sent photocopies of some of his Rxs to the Medical Practitioners Board. Problem solved!

In summary, be courteous but firm. Convince yourself that there is no reason why you should have to put up with any less courtesy than you extend to others. If you get it right it will pay dividends.

Jeff Lerner qualified in pharmacy in the UK in 1968. He has spent most of his working life in community pharmacy, and at various times has practised in Victoria, Western Australia, New South Wales and Queensland. He has now been retired for a year-and-a-half and lives in Melbourne, Victoria.

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  1. Amandarose

    The difficulty is self assurance when your young. The reality is many new grads have conniptions about potential interactions that are so rare it is not a contraindication – rather making the patient aware of what to watch for. It takes times to figure out what is a big deal and what is not. So many gray areas. I recall calling a specialist about one of these interactions that are more theoretical then real life in my first year out. It’s bloody embarrassing as the reference texts are about avoiding litigation as opposed to the naunces of risk benefits.

  2. Ron Batagol

    Great article Jeff and some really useful advice. To me, the key points are:
    Yes- assertiveness training would be invaluable ( with lots of practical role-play of confronting issues that can be solved with non-confronting, calm assertiveness, backed up by good quality evidence for your case) -please don’t use propietary guides to validate non-TGA aporoved uses and doses-AMH guidance amongst most useful.
    If, in the end, you judge that it’s not safe to dispense the script as written, validated documentation is essential, plus endorsement of script accordingly.
    Also, inform your Professional Indemnity Insurer. If a medico, a pharmacy colleague or other person with expertise in the relevant therapeutic area is contactable, that’s an added and invaluable bonus.
    Bottom line-as a profession we need to initiate a dedicated program to guide pharmacists in their early years to be able to confidently exert their legitimate and hard-won professional judgement and independence!

  3. Tamer Ahmed

    Great article however it doesnt really address the main source of decision autonomy in community pharmacy which is employment security.A pharmacist needs a pharmacy to practice unless he is a HMR pharmacist.Most community pharmacies these days are either managed by non-pharmacist managers or the owners have agreed to surrender their managerial autonomy to shadow owners.I have personally worked in pharmacies where they have policies to override your professional autonomy and this even includes hospitals.So you can train as much as you can using these concepts but when a customer or a GP calls and complains that you were difficult or aggressive although you were just practicing your autonomy.Its highly likely that you will be kicked out of your employment by getting you micromanaged into areas of discomfort

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