Does doctor—pharmacist power imbalance lead to harm?

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And do we need another death before we as a profession show real action, asks leading pharmacist

Prescribers and pharmacists need to better cooperate and communicate for the sake of patient safety, argues Dr Mark Naunton, Associate Professor and Head of Pharmacy at the University of Canberra.

In a recent editorial for the Journal of Pharmacy Practice and Research, he writes about the “profound impact” the story of Melissa Sheldrick had on him, after hearing it at a conference in Canada.

Ms Sheldrick’s son Andrew died after he received baclofen instead of tryptophan.

“On my return to Australia, I was saddened to read the coroner’s report on yet another patient death due to a medication,” he says, referring to a recent Victorian case.

Ian Gilbert died when dispensed methotrexate at a dose of 2.5mg twice daily.

The coroner ruled that Mr Gilbert’s death was “needless and entirely preventable”.

Dr Naunton notes that the pharmacist contacted the prescriber about the inappropriate dose, but was informed that the dose prescribed was correct.

“The prescriber was described by the pharmacist in the coroner’s findings as ‘firm, confident and resolute’.

“However, the pharmacist was not reassured by the prescriber about the (inappropriate) methotrexate dose; the pharmacist even changed the instructions on the medication label (and then changed it back).

“Why did the pharmacist dispense this lethal dose of methotrexate?” he asks.

“Did the pharmacist in this case feel disempowered? 

“In the coroner’s findings regarding the death of Ian Gilbert, it was noted by the pharmacist that she believed there was a power imbalance between the pharmacist and the doctor.

“In this case, the pharmacist was clearly knowledgeable and identified an error; perhaps if the GP had been more receptive and the pharmacist more assertive, then the outcome may have been different.

“Perhaps we need to reconsider pharmacists’ competence to practice and consider more overtly their competence to practice persuasively?”

Dr Naunton is not the only person to suggest this.

Just recently, experienced pharmacist Jeff Lerner wrote in the AJP arguing that the methotrexate case “indicates a real need for universities to provide assertiveness training during pharmacy courses”.

“Do we need another death before we as a profession show real action, rather than just publishing another error and hoping we learn our lesson?” asks Dr Naunton.

“I hope not. I also hope our medical colleagues will work with our profession to ensure doctor–pharmacist interactions are conducive to benefiting the patient.

“The time to change the way we communicate is now. Ian was a father: he didn’t have to die.

“Andrew was 8 years old: he didn’t have to die.”

Read Dr Naunton’s full editorial here.

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  1. pagophilus

    Patient scheduled to receive zoledronic acid, but last calcium result is from a month ago. Consultation with the doctor resulted in the doctor agreeing to go ahead without calcium result. Discussion among pharmacists resulted in pharmacists desiring a calcium level if possible. Discussion with pathology resulted in them being able to get a calcium result from stored sample which was used for other tests (calcium was forgotten to be ordered). “You can’t go against the doctor” says oncology nurse. I say to the other pharmacist “yes I can, otherwise I’d be giving daily methotrexate”. Ok, so not a life-threatening situation, but everyone, learn to stand up for yourself and for good clinical care, to doctors, nurses (some charge nurses can be bigger authoritarians/bullies than any doctor I’ve encountered) and anyone else (finance department, CEO’s and whoever else may get in the way of good clinical care).

  2. Ron Batagol

    A few thoughts on this very important issue:

    Firstly, as we are aware, the Pharmacy Board Dispensing Guidelines state that “ a pharmacist has to exercise an independent judgment to ensure the medicine is safe and appropriate for the patient, as well as that it conforms to the prescriber’s requirements”.

    I note that in the Editorial, Dr. Naunton suggests that:“perhaps we need to reconsider pharmacists’ competence to practice and consider more overtly their competence to practice persuasively?”

    I also agree, as suggested by Jeff Lerner, that the methotrexate case “indicates a real need for universities to provide assertiveness training during pharmacy course”.

    Such training would obviously reinforce the importance of “persuasive” practice”, necessarily backed up by systematic and thorough medication safety review through the usually readily-available references are critical factors to achieving this aim.

    However, clearly, the issue is much broader than that, over the working lifetime of a pharmacist practitioner.
    This is because, during their career, any pharmacist is very likely to be confronted many times with the perennial real-life tension between the supply of medication as prescribed, and, after carrying out the requisite professional diligence regarding medication safety, it then becomes necessary to discuss and if need, query any medication safety issues with the prescriber.

    Often ,this situation may occur many years after participating in assertiveness training or similar programs during their undergraduate studies.

    In this context, I note that, in the Methotrexate case, the Coroner recommended the PSA and Pharmacy Board set up an advice service to “embolden” pharmacists when there is conflict with a doctor.
    This possibility is certainly, in my view, worth exploring,and could be a very useful support service to pharmacists.

    However, In saying that, obviously, in any specific situation, an external “advice service” of this sort, cannot and obviously would never seek to, have any direct role in influencing a pharmacy practitioner’s legal responsibility to exercise independent judgement of safety issues in a specific situation.

    Such an “advice service” could, however, be a useful ongoing supporting mechanism in providing general guiding principles and strategies on effective assertive communication to individual practitioners, to enhance the level of their “assertive” discussions with the prescriber if required.
    In my view, all of this assumes that the pharmacist has systematically reviewed relevant references and guidelines on dosages and other specific relevant safety issues, prior to having the discussion with the prescriber.

    Finally, it goes without saying that documentation and recording of all such events needs to be undertaken, both for quality assurance and, if needed for potential medico-legal reasons.

    • Notachemist

      Ron pharmacists do already have access to an “advice service”. The Pharmacists’ Support Service (PSS) is manned by trained volunteer pharmacists and retired pharmacists who are able to support a pharmacist facing these situations. While we do not offer clinical advice we work with pharmacists calling us to problem solve these type of situations on a regular basis. PSS is available every day of the year between 8am and 11pm EST on 1300244910. For more information . In addition to PSS, members of PDL have access to 24 hour 7 day a week professional officers who are pharmacists with considerable experience. Hospital drug information centres also provide services in relation to evidenced base information, though they usually operate weekdays 9am to 5pm. Poison’s Information Centres which are available 24/7 are usually manned by pharmacists and can assist when information is required about safe dosing. Thus services are available and it is more important that pharmacists challenge the culture which hinders them from acting on their concerns. I see two issues here, one is that of the perception of a power imbalance and the other is the view that “if I refuse to dispense this someone else will”. Pharmacists are experts in medication and we need to feel confident in our knowledge and place the patient at the centre and raise concerns and if necessary refuse to dispense a prescription and annotate the script and tell the patient or carer why we are refusing to dispense the script.

  3. Notachemist

    Pharmacists facing these type of challenging situation can call the Pharmacists’ Support Service on 1300244910. The service is available every day of the year between 8am and 11pm EST. We do not offer specific clinical advice but we can assist any pharmacist, intern or student to work through the problem and discuss options for resolving it with the patient’s best interests in mind.

  4. B Lee

    I would never trust GP ever in my pharmacy life due to below standard practicing. So I would not dispense the script like this. Rather, I think it is important for pharmacists to be aware that we can actively refuse the supply if we are not sure or not right even though prescriber insists, given that it is definitely against the reference and we give patients alternative, “eg follow up with specialist who originally initiated the script or otherwise, get them to go to hospital etc etc. I would never go against the reference because GPs and doctors also learn from the references.

  5. Debbie Rigby

    Congratulations Mark on a really thoughtful and timely editorial. I think most pharmacists and GPs are weary of the continued comments in our pharmacy and medical media and social media.

    In the real-world GPs and pharmacists trust and respect each other’s roles in patient care.

    There may be a lack of consultation when new pharmacy services and programs are launched; and this needs to be corrected. Similarly community pharmacists should liaise locally with GPs when implementing new services, screening and health promotions.

    I think every pharmacist, regardless of where they work, has made an intervention when dispensing that has avoided an adverse event.

    Many of us have also experienced GPs who will not take phone calls from pharmacists. Or who are unwilling to listen and consider our concerns.

    Understanding the shades of grey in prescribing and clinical decision making can only be learned through experience. Good communication skills and relationship-management can help bridge the gap in interprofessional collaboration. This needs to start at university, and be nurtured through our careers.

    Understanding when graded assertiveness is required can be challenging. But our professionalism and focus on patient care requires this. Reflection on interactions with GPs can help improve outcomes and our confidence.

    It is worth noting that the MTX story has been reported in pharmacy media many times, but not so often in medical media. In this case the pharmacist correctly identified an inappropriate dose; and yet the GP ignored the pharmacist’s advice. Why hasn’t the medical profession and media highlighted the benefits of pharmacist’s interventions in protecting patients from medication misadventure?

    We should always be working together to ensure medicines safety.

    • Jarrod McMaugh

      Debbie, I think most people appreciate the sentiment of what you say, but let me ask you a few questions. (Although I expect you won’t answer)

      1) can you name a doctor who has spoken about pharmacists in mainstream or medical media positively in recent times

      1a) bonus points if the person you name doesn’t have any published articles that are critical of pharmacists

      2) can you name the last pharmacist-led service or initiative that medical groups have welcomed

      3) with regards to this point you make:
      “There may be a lack of consultation when new pharmacy services and programs are launched; and this needs to be corrected. Similarly community pharmacists should liaise locally with GPs when implementing new services, screening and health promotions.”

      Can you provide details of the last time medical groups consulted with pharmacists about new initiatives that they are intending to implement?

      Your last sentence is very important, but the problem is, medical groups and many pharmacists seem to think that pharmacists need to show this courtesy to doctors, but doctors do not need to reciprocate…. In fact the theme of your response here seems to be that pharmacists need to fix the problem that doctors create and perpetuate…… I can’t name a single pharmacist who goes out of their way to attack medical groups (as opposed to responding to inapropriate or unfounded criticisms from medical groups). In contrast, it almost seems like a prerequisite way to achieve political positions in medical groups is to criticise pharmacists or other health professionals.

      Yes pharmacists are sick of the friction…. And there has been significant efforts made by pharmacists to overcome this, but until doctors change their culture & learn to respect health professionals outside of their own colleges, then there is only so much that can be achieved.expecting change to come from us is the same as expecting your own child to change the behaviour of another child who bullies them at school every day…..futile & potentially dangerous.

  6. Michael Post

    A power imbalance is present in the GP / pharmacist relationship as community pharmacy relies on prescriptions from GPs and others to be viable. GPs do not rely on pharmacy to be viable and while we are there to protect the patient and support medico prescribing our role is confusing to many prescribers .

    It can be challenging to question the difficult or ornery ‘ hand that feeds us’ particularly when we lack comprehensive and confidential medical details in support of our position. Many simple pharmacy queries are dismissed in order to maintain the status quo .

    Medical education is beyond the scope of pharmacy education and this fact alone creates a power imbalance in the minds of those that cannot place a patient’s welfare above all else.

  7. Tamer Ahmed

    There are many good suggestions here however I didnt read anybody mentioning that the pharmacist’s diminished autonomy is mainly due to the poor work conditions and corporateisation.Without going through too many psychoanalytical assumptions the assertivness of any person comes from his finiancial security.Can we say that the current work conditions provide an atmosphere where its even moderately easy to exercise own assertiions without being labelled as difficult or antisocial and to be a subject for a complaint which would be dealt with from the perecpective of a customer not a patient ?The law has provided an employer with so many tools that he can use against an assertive health professional while the same health professional doesnt have many options except to complain to professional bodies.An employee pharmacist is stuck in a very tight position where his clinical decisions could affect his employment.I personally had pharmacy owners telling me that AHPRA doesnt pay your bills I do and had managers trying to assume the role of proprietor in pharmacy related affairs.Just to spice things a bit do you know that many pharmacy owners in a major banner groups hold 5-10% of ownership and report to a state manager like an employee every day .Do you really except these owners to uphold professional standards if they had a situation were there is a conflict between their financial intrests and patient safety ?

    • Jarrod McMaugh

      I think this is a bit “chicken or egg”

      Assertiveness is needed to gain adequate remuneration. This is not always the case, but it helps a lot.

      On the last point….. I do expect that, although do ithink it happens in 100% of cases in reality.,…..

      • Tamer Ahmed

        Usually remuneration is governed by 3 major factors technical knowledge ,experience , personal traits like (team work ,punctuality ,etc).Assertivness falls into the personal traits catetgory and hence can’t be a determinent factor in reumenration.If we apply this concept in reality a novice assertive surgeon reumenration would be higher than an experienced surgeon with a PHD ? does that sound logic to you ? or do you think that pharmacy lack the technical depth which makes experience and technical knowledge less favoured compared to personal traits ?I am not going to comment on your ex
        pectations that an owner with diminished ownership rights will be able to exercise his professional influence or not as its a judgment call on my side which is based on my observations

        • Jarrod McMaugh

          I’m aware of your experiences – and other pharmacists as well – which is why I say it doesn’t happen 100% of the time. (Although there’s a spelling error in my response that makes that ambiguous).

          Assertiveness will absolutely make a difference in starting pay, but has greatest influence in getting a raise over time.

          I was lucky though – my employers we always willing to work with me so I could get the income I felt I deserved (either that or I’m wildly convincing….. I think this isn’t even close to accurate!)

          It’s far more complex that whether someone is assertive for all the reasons you have said… But it is an important part of the negotiations, and it makes a lot of sense that you raised it here

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