Medical dominance: what can help?


doctor crossing arms

Pharmacists who experience dismissal and denigration from doctors may find their performance affected… and young, female community pharmacists may be particularly at risk

A paper presented at the Society of Hospital Pharmacists of Australia conference on the Gold Coast looked at how pharmacists react, personally and professionally, to doctors denigrating pharmacists, evading scrutiny and dismissal of pharmacist advice, among other behaviours.

Dr Karen Luetsch, course coordinator and lecturer at the Postgraduate Clinical Pharmacy Program, University of Queensland, said the study aimed to gauge pharmacists’ experiences of medical dominance and how it affects them personally and professionally.

While pharmacists’ role is well defined, their place in health care teams and collaboration is less well defined, she said, “and this is where medical dominance can come into play”.

”One way of preparing pharmacists for interprofessional collaboration is interprofessional education, which is implemented in many undergraduate programs, but that also can follow on in professional development in the workplace and postgraduate study.”

”We designed a study around the learning we delivered to our pharmacists which looked at the social dimensions of health care delivery including medical dominance, then they’re learning about interprofessional communication; and then they have to go out, practise, seek practice experience, and then reflect on those experiences.”

The researchers asked whether the pharmacists had perceived medical dominance in the workplace and also their feelings, behaviours and actions taken to resolve this tension as well as any expectations around the problem in the future.

Of the 77 pharmacists approached, 62 consented to having their reflections included in the study. More than half worked in hospitals but community pharmacists were also included in the study. Most of the pharmacists had been practising for less than three years, and were female.

Medical dominance was identified as having five main themes: denigration, or denial of the skills and role of pharmacists and other health professionals; evasion of scrutiny; dismissal or disparagement of evidence- or patient-based advice; demarcation against and criticism of pharmacy services; and “structural dominance,” where priority is given to medical practitioners in terms of access to patients.

“Pharmacists working in community pharmacy, quite a few described how they were questioned or attacked when they introduced vaccination services in their pharmacy,” Dr Luetsch said.

She said that while all the pharmacists had described an instance of medical dominance, thus the study did not determine whether any group was most likely to be affected by it, it was clear that there was a particular issue between young female pharmacists working in the community setting, and older male doctors.

Most of the encounters described were around doctors not accepting pharmacists’ advice, and there was a sense that the doctors could be “rude and arrogant”.

“For pharmacists working in communities, it was pretty clear-cut by upwards of 90% that their experience could be easily identified as medical dominance within our framework. In hospital it wasn’t quite so clear, and we’re still looking at that.”

In hospitals, up to half the encounters described could have been due to reactions to pharmacists’ ignoring grey areas in therapy and focusing on guidelines, compared to the community setting, where 90% of the encounters were classed as medical dominance.

Dr Luetsch gave examples, including from one interview where a pharmacist said that the problem was “rampant” in ICU.

“I have personally experienced a consultant say to a junior staff member before as that ‘pharmacy should not be making the decisions when it comes to medication dosing’,” one pharmacist said in the study, noting that this comment was made after the staff member suggested they talk to pharmacists about the dose.

In another case Dr Luetsch cited, the pharmacist was attempting to ascertain the patient’s weight and indication to ensure the dose of Clexane was appropriate. 

“Tell them it’s none of their business,” the consultant said when asked.

She said that while the study was limited in that it involved self-reporting rather than being observational, the researchers were very interested in how the pharmacists reacted to the episodes of medical dominance.

Pharmacists felt emotions that were “definitely not positive” after such encounters – and these emotions could be mapped to how the pharmacists described what they did next.

“It depended really on their degree of agency on what they decided to do.”

Some pharmacists felt resigned, while community pharmacists tended to feel that there was not much they could do at all; others developed workarounds for the problem. Pharmacists who felt angry may have been more likely to see escalation of the problem or even retribution, such as complaints to senior doctors or hospital management.

Medical dominance circumvents the governance role pharmacists try to take on, Dr Luetsch said. 

“The experience of medical dominance and other rejections of pharmacist advice has negative effects on pharmacists’ emotional response and that is a concern,” she said, saying there was a link between such negative emotion and performance in the workplace.

“Impaired performance is never a good thing in a high-risk business like health care. It certainly affected their role, in that they had to look at other solutions and workarounds, and affected, of course, interprofessional relationships. 

She said that instead of devising workarounds, pharmacists could instead learn to deal with therapeutic uncertainty, how to navigate professional boundaries and how to avoid interprofessional conflict.

A recognition of common conflict areas with prescribers could assist in devising strategies to strengthen pharmacists’ response and resilience; interprofessional and clinical skills would allow pharmacists to negotiate boundaries and grey areas.

The study made it clear that medical dominance did weaken clinical governance, she said.

 

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