Pharmacist prescribing: Good medicine?

Issue: BCMJ, vol. 49 , No. 2 , March 2007 , Pages 52-54 Editorials

As I pass into something closely resembling dotage, I find that the transition from “grey but youthful” to “grey and barely sentient” has some features that I worry might need some form of Gestalt therapy (whatever that is).

I find that my doctorish need to be obsessive about my compulsions includes a quick scanning of the newspaper every morning for proofreading errors (on average, 8 to 10 in both of our daily morning papers). Once I’ve satisfied that compulsion, I note the news items that have a health focus in case there’s something there that I want to rant about. Lightning-quick, knee-jerk ranting is one of the other interesting behaviors resulting from my voyage toward senescence and the one that seems most likely to crown me curmudgeon of the year.

My most recent rant began after reading an article that trumpeted that sometime in 2007, Alberta pharmacists will be able to assess and prescribe treatment for Alberta residents. The article stated that members of the Alberta College of Pharmacists will be able to “assess and triage each patient as required,” start “prescribing drugs to treat minor, self-diagnosed, or self-limiting disease conditions,” and may even take “full responsibility for establishing and maintaining a patient’s chronic drug therapy.”

After reading this and having to deal with the sudden gush of hydrochloric acid up my esophagus, I thought that I’d better rant on paper rather than at my breakfast partner. My in-house, long-suffering rant receiver has heard it all and now just smiles warmly, hits the tune-out switch, and my stream of invective does little other than provide some mildly bothersome background buzz to an otherwise enjoyable cup of tea. 

Pharmacologists know a lot about pharmaceuticals and I often ask them questions about drugs that I can’t quickly find in some database. Generally, pharmacists don’t hesitate to give help when physicians ask for it. Usually, they provide useful answers and frequently direct me to database resources for future queries. However, pharmacists are not physicians, and I have difficulty understanding how a pharmacist is going to know what is (and is not) a minor disease. If pharmacists will not have to decide whether a complaint is minor (they will apparently just prescribe something and hope that they are right), who is going to guide them? My guess is that doctors are going to be asked to do the guiding, get little or no compensation for agreeing to provide the service, and will be medically liable the moment they agree to help. If the pharmacist forgets to tell you that one little important piece of clinical information you need before you make a snap decision in the middle of a chaotic office day, guess whose gluteus maximus will be in a legal sling? 

I anticipate that soon after this legislation is enacted, Alberta’s helpful but clinically/diagnostically challenged pharmacists will find themselves in a number of situations each day that demand a level of clinical training and experience that they simply don’t have. BC has yet to follow Alberta into this new territory. The potential legal and ethical ramifications of doing so for BC’s doctors and pharmacists suggest that such legislation would best serve the interests of the office of the provincial treasurer alone. The ruling in Alberta raises a number of philosophical questions, including that of “conflict of interest,” but that only seems to be a problem if you’re a doctor. 

Self-diagnosis seems to be the part of the legislation that relieves the pharmacists from litigation worries—as long as the right drug is prescribed for an individual’s self-diagnosed pathology, it won’t matter that no attempt was made to make a correct diagnosis and treat the problem appropriately.

I’m sure most doctors will be interested to see what diseases are going to be included in the list of medical problems for which pharmacists are going to be allowed to prescribe and keep a clinical chart (i.e., take full responsibility for establishing and maintaining a permanent record of a patient’s chronic drug therapy). Patients will have another clinical chart in some pharmacy database that contains a record of their medications prescribed by their clinical pharmacist (not their physicians) that will potentially be shared only if a doctor is aware of and asks for it. This adds the ugly spectre of turf protection into what already looks like a potential war zone, with patients caught in the cross fire. 

I have good relationships with the majority of my pharmacist colleagues, a number of whom are great friends, and I don’t mean to diminish their importance to our health care system. However, in my opinion, this legislation, besides being ill-advised, is dangerous. I feel sorry for the pharmacists who are going to be trapped in a no-win, legally tenuous situation, and I can’t understand why we haven’t seen more on this from our provincial and federal organizations or from any of the various colleges across the country.

—JAW

James A. Wilson, MD. Pharmacist prescribing: Good medicine?. BCMJ, Vol. 49, No. 2, March, 2007, Page(s) 52-54 - Editorials.



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