The pharmacy schism that shouldn’t exist

non-dispensing pharmacists: pharmacist sitting behind desk with pen and small pile of meds

Does the schism between clinical pharmacy and community pharmacy actually exist? wonders Taren Gilland could it be a barrier to pharmacists offering professional services?

During a session at APP2015 on the expanded scope of practice for pharmacists, the term “clinical pharmacist” kept being mentioned, as distinct from the word “pharmacist,” which got me wondering: why is it that all pharmacists who have done a Bachelor or Masters degree in pharmacy cannot consider themselves clinical pharmacists, regardless of their place of work?

This year I made a career change that I never thought I would: I am a hospital pharmacist (I can almost hear the gasps of the community pharmacists I know who are hearing this for the first time!). I have the privilege of helping run a pharmacy department in the role of Deputy Director of a NSW regional hospital.

The learning curve is steep. I am seeing doses and diagnoses I’ve only ever read about in textbooks.

Hospital pharmacists have no doubt that they are “clinical pharmacists”, from the intern all the way to the Pharmacy Department Director, despite the fact that the Director still has to deal with budgets, payroll, HR, stock supply issues, external accreditation and reporting to a general manager (who is not a pharmacist).

From collaborating with allied health and medical staff to engaging in regular continuing education, there is absolutely no doubt in the minds of the pharmacists in my department that they are playing a clinical role. Hospital pharmacists see acute health situations more frequently than their community counterparts, who deal in chronic and preventative health situations.

So why is it that so many community pharmacists I speak to believe the role they play is not clinical, and why does the schism between community and hospital pharmacy exist at all?

I suspect this crazy notion has its roots from our studying dayseven when at University it seemed like the smarter kids were the ones who got the hospital intern placements and those of us who were somewhere in the middle were destined to work “in a shop selling jelly beans”.

Bryant et al. in a 2009 study from the University of Auckland concluded that “there are significant barriers to community pharmacists increasing clinical services, both from the community pharmacists themselves and from the general practitioners. Attention to change management in a complex environment will be necessary if community pharmacists are to change their role toward more clinical services.”

The word “clinical” relates to the observation and treatment of actual patients rather than theoretical or laboratory studies, implicating pharmacists as problem solvers and both hospital and community pharmacists have this role.

My first love will always be community pharmacy and its farrago of PBS price reduction, discounting, escalating rental situations, and other increasing costs and sustainability challenges. A community pharmacist is juggling many competing priorities on any given shift: customer service, stock control, PBS claim management, checking DAAs.

Many hospital pharmacists would never encounter these considerations, some rarely so, but is being a clinical pharmacist really at odds with making (or saving) money to create a profitable and sustainable community pharmacy model?

With the un-shackling of the supply and service elements for dispensing in the 6CPA there is an opportunity for pharmacists to display their clinical knowledge to change the perceptions of the consumer, GP and community pharmacists themselves regarding their clinical role. Good processes, engaged staff and strict operational efficiency are the key in the fight against increasing costs in community pharmacy.

One of the reasons for my transition into a hospital role is to look at the challenges in public health. Two to 3% of hospital admissions are from medication misadventure; this soars to 30% for patients above 65 years of age.

Early intervention from a community pharmacist has a huge impact on taxpayer funded health care.

To use an analogy, if we only had police SWAT teams (hospital pharmacists), and our street patrol police (community pharmacists) were not doing a great job, the SWAT team would be overworked and we’d need a SWAT police force.

Both “forces” are needed. A community pharmacist can educate consumers and influence their quality use of medicines and behaviour while a hospital pharmacist rescues and manages acute situations.

Now that I have seen the “other side” I want to reassure the community pharmacists out there who are feeling “less than clinical”, when you are looking at your HMR accredited colleagues, the pharmacist in the GP surgery or that hospital pharmacist who is free on the weekend while you are at work on a Sundaythat the role you play is incredibly important and undeniably clinical.

Whether it is advising the mum of an infant on the safe use of paracetamol or ibuprofen to reduce a fever before febrile convulsions occur and they end up in the Emergency Department at 1am; or looking at your 10th rash for the day (but this one seems to start in the centre of the elderly gentleman’s back like a band…) and you are able to get him a GP appointment straight away to start an anti-viral for that shingles, the work that you do in a primary healthcare position is invaluable.

Pharmacists who are also small business owners provide services seven days a week and the community pharmacist is manning that station.

I encourage you to see yourselves as clinical despite the other competing priorities. If you are feeling like you need to brush up (as I constantly do in my new role!), form a journal club, do some online CPD or attend a conference… you never know who might need your help in the pharmacy next.

Taren Gill is the 2014 Pharmaceutical Society of Australia Young Pharmacist of the Year.

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  1. Jarrod McMaugh

    Most pharmacists in community don’t see themselves as performing a clinical role because the types of conditions we see fall in to two areas:
    – Chronic conditions that are stable
    – Acute conditions that are minor ailments.

    Pharmacists need to remember that dispensing is a clinical role that may seem robotic, but still requires you to apply your clinical expertise. It’s like watching grass grow…… Your role is maintenance and getting the weeds before they cause problems. It’s easy to lose sight and let the grass get too long (too overwork the analogy) but if you talk with your patients regularly, and apply your clinical skills, you’ll be aware of your clinical input

  2. Notachemist

    Community pharmacists establish long term relationships with regular customers over many years and become an essential part of their health care team. They also hone skills in primary care, diagnosis and advice about minor ailments. Hospital pharmacists often have specialised knowledge about particular disease states and management of acute disease. However both groups have expertise in medication management and medication safety. In my opinion all pharmacists are the medication experts in healthcare. The term clinical is misleading. We all contribute to patient care by optimising the use of medication.

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