After a pharmacist was reprimanded for dispensing a medicine which killed her patient, PDL offers some advice on discussing worrying scripts with doctors
Earlier this week, the AJP reported on the case of Ian Gilbert, a 77-year-old man who was prescribed methotrexate for a psoriasis flareup in 2015.
He was prescribed 5mg a day for five days, with five repeats. The pharmacist contacted the doctor to express her concerns, but after a discussion in which the doctor was “firm, confident and resolute,” she dispensed the drug, along with a CMI and advice to attend a scheduled follow-up GP appointment.
Mr Gilbert subsequently died, and the pharmacist has now been reprimanded and conditions imposed on her registration.
John Guy, professional officer with PDL, told the AJP that pharmacists having their concerns dismissed by prescribers is “an age-old problem”.
“I think it’s slowly getting better, but traditionally, the old-school doctors didn’t want any interaction with pharmacists – they thought they were wasting their time,” he said.
As younger GPs enter the profession, the relationship is becoming more respectful, he said, “as they recognise that pharmacists have the clinical knowledge to discuss these issues”.
But anecdotally, pharmacists report that when they ring doctors, some are still “rude, dismissive and unhelpful”.
“It occurs more often than it should,” Mr Guy said.
“I think a lot of older male doctors are also more dismissive of younger female pharmacists.”
Another issue is getting past the reception desk.
“A lot of the time, the receptionist will say the doctor is busy and won’t put the call through,” Mr Guy said. “A timid pharmacist will take that on board.”
In these cases, it’s a common occurrence for the doctor to never call back.
“If it’s urgent, the pharmacist needs to be politely assertive and say that it’s urgent, that they’re willing to hold, and not be fobbed off.
“Pharmacists have their duty of care to that patient. That’s why they need to speak to the doctor if they have concerns, and refuse to dispense if they think it’s unsafe and explain the reasons why.
“Often this is easier said than done if you’ve got an assertive older doctor saying ‘don’t question me,’ and younger pharmacists often feel intimidated.”
He said that pharmacists must be resolute, however, as not only can the consequences for the patient be disastrous – as in the case of Mr Gilbert – but pharmacists can face not only regulatory action but “anything up to being individually, personally sued by the family of someone who is deceased, or someone who has been injured”.
“Don’t be shy and put off if the doctor is dismissive and says, ‘Just do it’. You need to politely push back and explain your concerns. And there are some good doctors out there who are quite willing to listen and discuss them.”
It’s also important, when declining to dispense a script, not to push the problem onto another pharmacist, Mr Guy added.
While pharmacists should not retain the script, as it is the property of the patient, Mr Guy agreed with a comment by reader Jarrod McMaugh, in which Mr McMaugh advised fellow pharmacists to “annotate the prescription to show that you refused to fill it, so that the next pharmacist also knows there is an issue”.
“You should definitely annotate it to let other people know you perceive a problem,” Mr Guy said.
“Hopefully that opens their eyes to further questions, and they too will contact the doctor and refuse to dispense it.
“Think about what you’re dispensing. Don’t be an automaton – think of the consequences.”
When contacting doctors about a problematic script, Mr Guy had the following advice for pharmacists:
- Don’t apologise when calling… you have done nothing wrong.
- Doctors are time poor so be concise and avoid chit chat.
- Speak respectfully but confidently.
- Have references (AMH, MIMS etc) readily available to quote doses and practice points etc.
- If you are calling about unavailable medicines, have several alternatives to suggest that have been verified as available.
- If you feel unable to dispense due to safety concerns, clearly state your reasons with references provided.
- If a matter is urgent but the receptionist states she will request a call back, firmly mention the matter is urgent and your call will be brief. All too often, prescribers fail to call back.
Pharmacists can contact the Pharmacists Support Service on 1300 244 910 for peer support related to the demands of being a pharmacist in Australia.
Members can call PDL on 1300 854 838 for support from a Professional Officer.