Pharmacist vs Doctor

Image by LUEK.

Why isn’t collaboration the norm between doctors and pharmacists? wonders Angelo Pricolo

A patient went to see her doctor about a nagging ailment. The doctor asked if anything had been done about the problem thus far.

The patient replied she had only spoken to her pharmacist about it, to which the doctor snubbed, “And what crazy advice did you get from your pharmacist?”

“She told me to come and see you.”

Why does so much animosity exist between these two key health professionals in Australia? Was it always like this or have things gotten worse? Certainly there are many working relationships that disprove the common belief that pharmacists and doctors are locked in a turf war. But unfortunately many confirm it.

Addiction medicine has always attracted me and so right from registration I have attempted to increase my knowledge base in this area. After establishing a good working relationship and eventually a friendship with an addiction medicine specialist, I quickly organised sessions where I sat into consultations with the doctor and consenting patients.

This cemented the pharmacist/doctor relationship and importantly from day one created benefits for patients. Information was free-flowing and myths were dispelled as patients were propelled to centre stage. We used our combined knowledge to solve sometimes complex and other times simple but persistent problems.

Sitting in the room together demystified the roles and encouraged reciprocal visits from the doctor to better understand the landscape and challenges in the pharmacy. Barriers started to fall away. Subsequent telephone conversations were more fruitful and quite frankly the job became more rewarding.

I can honestly say that many patients really did benefit. They were often empowered by extra benefits and comforted by knowing two people were there to help and consider their health.

But it is clear that these close relationships and the sharing of information is not always the norm. I’m not sure why.

I have always welcomed and enjoyed a visitor in the dispensary if they were interested in seeing how things worked. Equally the handful of doctors I have hosted have benefited from the exercise.

More than ever inter disciplinary education is happening at various tertiary institutions and this should promote good work ties. So maybe in the future we will see more collaboration and less confrontation.

Doctors sometimes cite fragmentation of care if a pharmacist begins to take on a task they have historically not done. But if a pharmacist has the capacity to undertake this role within their scope of practice then it should be about choice for the patient not protecting turf.

Vaccinating is a case in point. It really is not too different from dispensing pills or potions just that the medicine is in fact administered upon the doctor’s advice.

In most countries around the world pharmacists routinely administer a range of medicines by intramuscular or subcutaneous injection. But when we tried to launch this in Australia there was so much opposition, some began to doubt the wisdom of the initiative.

Although, it makes a lot of sense. Doctor sees patient, culminating in a diagnosis and prescription. Currently if that prescription medicine must be administered, the patient must visit the pharmacy then return to the doctor. Often the duty nurse injects the drug on the subsequent visit without any doctor involvement.

In another scenario: patient visits the pharmacy with their prescription and the medicine is administered, when appropriate, at the pharmacy. No need to wait for another appointment at the doctor, or to worry about safe storage or transport of the medicine. It sounds pretty easy for the patient, no wonder it’s caught on around the world.

Fortunately perseverance led to this successful outcome and with respect to influenza vaccination many pharmacists have now provided this service to hundreds of thousands of Australians. Pharmacists in Victoria, and hopefully soon in other jurisdictions, can also administer the Schedule 8 long acting injectable buprenorphine (LAIB) to treat opioid addiction. Surely this should open the door for many more injectable products?

As we battle through the ramifications of a pandemic how thankful should we all be that the profession has finally been given the green light to roll out the COVID vaccination. Access and choice.

But when the shoe is on the other foot, pharmacists have not agreed with doctors stocking vaccines and effectively bypassing the pharmacy. This would mean the doctor was diagnosing and dispensing. Why is this different?

If doctors want to dispense medicine as well as prescribe then let’s get a few things straight. Appropriate storage and labeling is an essential, legal requirement. Pharmacists are compelled to adhere to the regulations, hence so too must the doctors. It’s about patient safety.

It is easy enough to grab a vaccine from the fridge and stringent protocols must be met to safely do this. But if a medicine is handed over to a patient not just storage must be considered.

Medicine dispensed to a patient must have a label affixed with all relevant information. This includes the patients name, among other essentials we as pharmacists take for granted. Instructions for proper use, cautionary labels, refrigerate stickers, expiry dates and the list goes on…

On many occasions I have found myself explaining medicine to a patient that a doctor has just handed over during a consultation. Sometimes this takes the form of a pharmaceutical sample pack but unfortunately it has even been loose pills in a blank envelope!

And we never want to find ourselves in a situation where doctors stock a limited amount of drugs and thus become restricted in the range of medicine they prescribe. This would disadvantage the patient and surely not be a situation Medicines Australia or other regulatory bodies would support.

When we consider labeling, why would the bar be lowered for doctors? It cannot and so although I fully trust doctors to ethically separate prescribing from supply of medicine, I’m not convinced they would take on dispensing to the standard required.

If they do, then we cannot stand in the way of their dispensing, as pharmacists make a case for prescribing. But doctors would also need to keep a range of medicine, including generics to give the patient the choice and effectively this would start to resemble a pharmacy with dispensing procedures in place too.

Ordering, storing and supplying medicine has been the domain of pharmacists…for good reason. They get logistics. I’m not sure doctors have this in their skill set or the desire to take it on.

It’s all about being able to safely provide patients with accessible healthcare. Nobody wants to work outside his or her scope and put patients at risk.

So let’s hope the uture brings more working together and less conflict between the two important pillars of the Australian health system. This can only happen when we decide to make the patient the centre of our abundant health care system.

Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.

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