Editorial

Pharmacist Scope of Practice: A Response to the 2002 ACP-ASIM Position Paper

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Times have changed since pharmacists were primarily concerned with licking, sticking, counting and pouring pharmaceuticals.  A shift from a product-centered profession to a patient-centered, outcome-oriented profession is well underway and is already firmly established in institutional practice.  In recent years several studies have demonstrated that pharmacists practicing in direct patient care roles as part of multidisciplinary care teams not only reduce overall health care costs but morbidity and mortality as well (1-3).  It is perhaps in response to this “pharmacy movement"(4)  that in January 2002 the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) published a position paper describing their perceptions of the pharmacist’s scope of practice (4). 

The physician-authored paper accurately presents available data supporting the roles of pharmacists in various patient care settings.  It acknowledges the aspirations of pharmacists as described in the American Pharmaceutical Association’s definition of pharmaceutical care and upholds the necessity that pharmacists be remunerated for their cognitive services.  Wisely, the paper supports that pharmacists take an active role in educating physicians about drug use.  Pharmacists as immunization providers is also advocated. The authors even provide a detailed account of the multitude of progressive roles undertaken by pharmacists with the support of state legislatures. 

The paper outlines five positions on the scope of pharmacist practice starting with support for research into the effects of pharmacy automation and the move to the all-Pharm.D. degree on pharmacy practice, and concludes with a position reiterating support for therapeutic interchange programs which is similar to the position of the American College of Clinical Pharmacy (ACCP) (5).  What lies between these benign stands are more contentious positions concerning collaborative care and the value of pharmacists intervention.

The ACP-ASIM position on collaborative care supports "physician-directed, pharmacist-physician collaborative practice agreements limited to pharmacists involvement in patient education and hospital rounds under the following conditions: (i) expanded roles of pharmacists should not be solely based on cost-savings; (ii) the responsible physician and pharmacist should be compensated for their time spent on collaborative services; (iii) the physician should solely determine if a relationship will be formed with the pharmacist; (iv) the physician should solely and individually refer a patient to a pharmacist; and (v) only the physician can and will diagnose the patient’s condition prior to any referral."

The idea asserted by the ACP-ASIM that a patient shall not form a relationship with a pharmacist unless authorized to do so by a physician is reduced to absurdity when one considers the following: 

  1. The sheer number and accessibility of pharmacists far exceeds that of physicians.  Patients have always sought the advice of pharmacists on a broad range of health issues.  In this context, pharmacists have been recommending, initiating, monitoring and modifying drug therapy for decades. They have been independently educating patients about drug therapy all along.  Patients have been making informed decisions about prescription and non-prescription drugs based on this information.  The pharmacy profession’s efforts over the last decade have been aimed at constantly improving pharmacists’ skills in providing this type of care.  Patients decide whom they wish to consult for health advice and the value of that service to them.
  1. The very act of writing a prescription invokes the formation of a professional relationship between pharmacist and patient and all of the legislated, mandated, ethical and professional responsibilities inherent therein. Do physicians long for the days past when they could prescribe an NSAID to a patient for joint pain without informing them of the risk of death due to upper gastrointestinal bleeding, expect that the pharmacist won’t “undermine” their prescription by doing the same, and assume the patient will faithfully take the drug as directed?  The pharmacist's foremost duty is to the patient, not the physician.
  1. In most institutions, the pharmacist’s duty to independently assess and strive to ensure appropriate drug therapy on a patient-specific basis is a Medical Advisory Committee decreed policy.  Such policies partially arose from the need to reduce the risk of avoidable adverse drug events resulting from misprescribing by physicians.
  1. Experience dictates that physicians lacking appropriate drug therapy skills are frequently unaware of this deficit.  That these physicians should be relied upon to seek advice and refer patients for pharmacotherapeutic consultation is not in the best interests of patients.
  1. Though we do not assert that all pharmacists are trained as diagnosticians, the reality that pharmacists interpret the complaints of scores of patients every day, form correct diagnoses and initiate and monitor appropriate drug therapy must be acknowledged.  Patients would not tolerate any attempt to limit the pharmacist’s ability to provide this advice, nor could any nation’s health system bear the cost of having these complaints referred to physicians, as the ASP-ASIM apparently desire.

Pharmacists have already established themselves as direct patient care providers in many settings where justification based on cost savings alone is not necessary (1-3).  Despite this, the necessity for provision of cost-effective and safe care in an era of skyrocketing cost and complexity of drug therapy has allowed motivated pharmacists to make great strides in expanding their scope of practice.  No data is presented by the authors of the ACP-ASIM paper which assert that the wide variety of initiatives undertaken by pharmacists has resulted in harm or have in any way been detrimental to patients.   

Much of the ACP-ASIM’s concern centers on the perceived differential between “hands-on” patient care training in PharmD programs and medical schools.  The debate about the sufficiency of the pharmacotherapy training imparted in most medical schools is one for another day. The ACP-ASIM’s statement that “physicians are qualified to…treat patients, while pharmacists expertise lies with pharmaceuticals” is cryptic, and their position that “decisions about the most appropriate drug therapy for a patient’s condition are often subtle and require a level of experience and training that is not provided in obtaining a PharmD degree” is objectionable.  Neither group has sufficient evidence to properly support or refute ACP/ASIM's antiquated opinions. However, thousands of highly trained, experienced, patient-oriented pharmacists adept at interpreting the subtleties of patients’ drug therapy needs are disproving this statement every day. 

ACP-ASIM also opposes independent pharmacist prescriptive privileges and initiation of drug therapy. This is not surprising given that this is one of the most sensitive areas of the “turf battle” between the professions, including that brewing between nurses and physicians.  As already stated, pharmacists already have prescriptive authority for patients seeking therapy in a community pharmacy in which the pharmacist can prescribe from a wide array of over-the-counter medications.  The ACP-ASIM paper nicely catalogues the many other areas where prescriptive authority is being exercised or evaluated, such as emergency contraception, anticoagulation, diabetes management, and numerous other “disease management” programs.  The experience being accrued in these and other jurisdictions will ultimately provide the data required to define what initiatives work best, what patients prefer and which result in the best outcomes. The ACP-ASIM’s lack of support for these initiatives is out of step with the demand by patients for such services and the reality that patients are already benefiting from them.  

ACP-ASIM's statements such as “pharmacists can educate physicians on drug interactions and cost savings and educate patients on drug safety, while physicians provide safe, effective care to patients”, fuels exactly the “turf battle” the physicians claim in their paper that they want to avoid.  Such marginalizing statements belie the underlying aim of the ACP-ASIM's position, which seems to be to protect the domain of the physician rather than to support a multidisciplinary and balanced approach to patient care.  This ridiculous attempt to reduce a profession to discrete tasks such as those named while ascribing to physicians the exclusive right to “provide safe, effective care to patients” shows ACP-ASIM's lack of insight about the rapidly evolving multidisciplinary health system. 

What the ACP-ASIM position paper stridently aims to assert is that physicians are already providing high-quality safe, effective drug therapy to their patients and that pharmacists, while potentially helpful (though annoyingly time-consuming (4)) assistants in this regard, ought not to interfere in that provision.  The alarming rates of prescription drug-related morbidity and death in North America are a stark reminder that this is not the case (5-14).  Informed consumers demand that this situation be improved.  Neither physicians nor pharmacists are providing the care necessary to avoid this needless suffering. Turning back the clock on pharmacist roles and limiting access by patients to pharmacists, even if physicians had the authority to do so, would not serve the best interests of our patients.   

The ACP-ASIM could be forgiven for their extreme traditionalist positions if they were aimed at the lowest level of pharmacist practice.  Indeed, not all pharmacists are sufficiently trained, motivated, experienced, ethical, or skilled enough to provide high-level pharmaceutical care to patients.  Neither, for that matter, are all physicians.  The profession of pharmacy, like medicine, has evolved to include a wide array of professionals with diverse and varied levels of training, skill and experience.  Fortunately, enhanced responsibilities for pharmacists have been limited mainly to those who obtain specialized training and achieve certification in various forms.  The position paper; however, purports to describe the “scope of practice” of pharmacists.  In this attempt, they have accurately described that scope as it existed 20 years ago.  The ACP-ASIM appears to desire a return to a time when pharmacists dutifully told patients in response to their drug therapy questions, “I shouldn’t answer that, you’ll have to discuss that with your doctor.”

It is doubtful that the conservative and demeaning ACP-ASIM position statement will have much impact on the pharmacy profession who, supported by numerous state and provincial legislatures, have embraced the role of drug therapy providers and competently provide for the needs of their patients.  They do this within a complex array of collaborations with physicians ranging from total independence to direct supervision.  Ultimately patients, not physicians, will decide which services they value and how much. 

Peter J. Zed, B.Sc.(Pharm), Pharm.D.
Peter S. Loewen
, B.Sc.(Pharm), Pharm.D. 

Publishing Editors
The Journal of Informed Pharmacotherapy

J Inform Pharmacother 2002;8:1

References 

  1. McMullin ST, Hennefent JA, Ritchie DJ, Huey WY, Lonergan TP, Schaiff RA, et al. A prospective randomized trial to assess the cost impact of pharmacist-initiated interventions. Arch Intern Med 1999;159:2306-9.

  2. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267-70.

  3. Gattis WA, Hasselblad V, Whellen DJ, O’Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Arch Intern Med 1999;159:1939-45.

  4. American College of Physicians-American Society of Internal Medicine. Pharmacist scope of practice. Ann Intern Med 2002;136:79-85.

  5. Guidelines for therapeutic interchange. American College of Clinical Pharmacy. Pharmacotherapy 1993;13:252-6.

  6. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc 2001;41:192-9.

  7. Johnson J, Bootman L. Drug-related morbidity and mortality. A cost of illness study. Arch Intern Med. 1995; 155:1949-56.

  8. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs and attributable mortality. JAMA 1997;277:301-6.

  9. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Peterson LA, et al. The costs of adverse events in hospitalized patients. JAMA 1997;277:307-11.

  10. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200-06.

  11. Schneitman-McIntire O, Farnen T, Gordon N, Chan J, Toy W. Medication misadventures resulting in emergency department visits at an HMO medical centre. Am J Health-Syst Pharm. 1996;53:1416–22.

  12. Moore N, Lecointre D, Noblet C, Mabille M. Frequency and cost of serious adverse drug reactions in a department of general medicine. Br J Clin Pharmacol. 1998;45:301–308.

  13. Tafreshi MJ, Melby MJ, Kaback KR, Nord TC.  Medication-related visits to the emergency department: a prospective study.  Ann Pharmacother 1999;33:1252-7.

  14. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug reactions in elderly patients presenting to the emergency department. Ann Emerg Med 2001;38:666-71.


Reader Responses to the Editorial, "Pharmacist Scope of Practice: A Response to the 2002 ACP-ASIM Position Paper"

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To the Editors:

Congratulations on your recent editorial on the response to the 2002 ACP-ASIM Position Paper on The Pharmacist's Scope of Practice. I very much, as you did, felt that this was a "fearful" response concerning loss of turf and that despite being portrayed as supportive was anything but. It is intriguing to me that the traditional healthcare providers seem to be more concerned about battling among themselves rather than joining forces to deal with some of the nontraditional providers who actually undermine healthcare.

Obviously we have still a long way to go.

Charlie Bayliff, Pharmacist
London Health Sciences Centre
London, Ontario, Canada


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To the Editors:

I think that we need to step back and not be too discouraged by the nature of the ACP paper. I agree with your passionate and eloquent response but we need to remember for every UBC/similarly residency trained+/- PharmD with a few years of practice experience, or keen community pharmacist, there are several pharmacists out there in drugstores and hospitals with limited clinical training bugging physicians multiple times a day with trivial issues or worse, making therapeutic arguments without adequate information or understanding of clinical relevance. There are also an alarming number of pharmacists who, unlike ourselves, do not feel comfortable taking on more patient care responsibility. They feel sufficiently challenged and busy with the dispensing process and leaving clinical decisions -no matter how minor, to physicians. I think this pattern is limiting the shift of the profession from being product based to knowledge based.

We also have to remember that there are roughly 5,000 more physicians than pharmacists in BC (about 8,000 MSP billers vs. about 3000 pharmacists). So if even half of us take up the call to provide proper pharmaceutical care, we will still be very short-staffed. A case in point was an ongoing discussion I had with a public health physician in charge of a provincial vaccination program a couple of years ago. She was lamenting that they didn't have enough staff to vaccinate all the people that needed vaccination and how poor vaccine record keeping was. I promoted pharmacists to her as great resource to improve things on both fronts. At first she dismissed my suggestion as "not in keeping with the traditional doctor/nurse model". I pointed out the flaw in her logic and she had to agree that pharmacist administered vaccination and record keeping was worth pursuing. Unfortunately, when she did pursue it with the provincial pharmacy organizations, she was told that there was little interest among their members in administering vaccines (citing workload, training and liability concerns). So I felt a bit sheepish to say the least.

Until we get our own house in order - of which the first step is working with the colleges of pharmacists and physicians & surgeons to eliminate regulations that limit the pharmacists ability to make even basic (e.g. dosage form selection) independent pharmacotherapy decisions AND implement regulations recognized by all health professionals that obligate pharmacists to be accountable for clinical interventions - I'm afraid we're at an impasse.

Once pharmacists are gradually held accountable for more & more important clinical decisions, then they will be forced to step up to the plate and embrace pharmaceutical care fully. We won't gain recognition for being able to provide "advanced" patient care until more of us actually do it. Talk is cheap. We're still the number 1 or 2 trusted profession in surveys, so we need to proceed in a manner that maintains that trust in the public's eye - a big part of that is their knowledge that we work co-operatively with their doctors to look out for their best interests.

If you read the editorial in the Feb 19th AIM responding to the ACP position paper by a pharmacist from Walmart in the US; I think that provides a useful first step in this dance with the docs....just having the internal medicine dinosaurs recognize pharmacists is a great opportunity to build on...we have to now win them over one at a time.

Bruce Lange, BSc.Pharm., Pharm.D.
Pharmacotherapeutic Specialist, Royal Columbian Hospital
New Westminster, BC, Canada


To the Editors:

I have recently read your response to the Annals Of Internal Medicine Scope of Pharmacy Practice Paper. To date I have not read a more accurate and truthful analysis of this "paper" and our profession. The two authors are right on the mark with 100% of everything they have written. My only disappointment is that such a well written and researched response is not more widely available to pharmacists, physicians and patients. 

I have taken the liberty to send it to my pharmacy department at Beth Israel Deaconess Medical Center, and it has then been sent to most of the major medical centers in the Boston area. Keep up the good work!

Pharmacy Practice Resident
U.S.A.


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To the Editors:

I have recently read the article published in JIP by Drs Zed and Loewen commenting on the Annals Of Internal Medicine Scope of Pharmacy Practice Paper. What has not surprised me was their passion for advancing the profession of pharmacy, which I absolutely concur with. However, what does concern me is that they had to write this article in the first place.

The profession of pharmacy needs to stand up and re-evaluate what are the priorities. When physician groups are writing position statements with regards to pharmacists roles, we need to take a second look at what we are doing, or at least what physicians think we are doing. When trivial legislation prohibits the pharmacist from making a professional decision, it is not surprising that physicians think most pharmacist "lick, stick and pour".

For example, if a physician writes a prescription for a topical product and it comes as both cream or ointment, the pharmacist is obligated to call and ask the physician "cream or ointment?" ...and probably annoying to the physician. Could not the pharmacist just speak with the patient and together make a decision?

When the patient has no more refills or needs an extension of medication until their next appointment, the pharmacist is obligated to call the physician and probably speaks with the receptionist. Authorization from a receptionist... what's next?

I was recently told of a patient who dropped their tablet of fluconazole on the floor and it got wet. When she called the pharmacist and explained, the pharmacist told her that she needed another prescription in order to give her another tablet. What do you think the physician's perception of that pharmacist is now when she explains to her doctor about what happened?

It is with these attitudes and barriers to the profession that gives other groups the perception that pharmacists are just "paramedicals".

I stand up and applaud Drs Zed and Loewen for showing leadership for pharmacy practitioners who are eager, willing and able to advance our profession. Now every pharmacist and regulatory body should adopt such passionate view points, then maybe we would not be in this situation.

Shallen Letwin, B.Sc.(Pharm), Pharm.D.
Pharmacist
Fraser Health Authority (MSA Hospital)
British Columbia, Canada


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To the Editors:

As I read "Pharmacist Scope of Practice: A Response to the 2002 ACP-ASIM Position Paper" by Zed & Loewen, I could not help but again feel ashamed of my profession. How many times are we going to whine about wanting more power? Are we so power hungry that we must get flustered over such an article? Having recently attained my Pharm.D. I can assure you that we are not capable of diagnosing illness. We are not educated in that area. Most schools barely cover enough anatomy to completely understand a disease state. There is a huge amount of detail that is left out for us. There are many variables that pharmacy students are not prepared for. The Pharm.D. students are now being taught how to give an abdominal exam, listen with the stethoscope, and other clinical exams in a one semester course. I would not trust any of them to diagnose my illness. What is the value of that anyway? Do we really think that we are going to catch something that the other 5-6 physicians/residents that check daily are going to miss? Most patients are not comfortable with a pharmacist laying hands on them anyway. Why do we want to bring that dark cloud over this profession anyway?

Diagnosing and prescribing have always been the physician's role. Why suddenly do we wish to take part in those activities? We are specialists in drug regimens and products. We know what is out there, how it works, how much it costs, and the data supporting its efficacy. It is our ability to guide the physician towards appropriate therapy that is our true value. The decision to accept this advice is ultimately up to the physician. A practicing pharmacist can now purchase liability for 2 years for less than couple hundred dollars. Do we as a profession want to be burdened with the incredibly high costs of insurance in order to say we can diagnose and prescribe? In the few states that pharmacists are actually prescribing, how many actually take advantage of it? This profession needs to realize its boundaries and not open up a can of worms in order to fulfill its ego. The doctor must be asked about any changes because he is ultimately responsible. If you really want to play doctor, and are not happy with the defined boundaries of the profession, go to medical school. (physician assistant school might work too)

Leave the rest of us out of it.

Sincerely,
A.T. Pharm.D., BSc (Pharm)
Pharmacist
Rutgers University College of Pharmacy
New Jersey, USA


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To the Editors:

There have been several editorials in regard to "Pharmacist Scope of Practice: A Response to the 2002 ACP-ASIM Position Paper" by Zed & Loewen, and many of them thought provoking. However, I write now not to comment on the position paper itself, but on an editorial by a newly licensed pharmacist from NJ. I find it discouraging that a fledging pharmacist with virtually no practice experience feels he/she so well understands the practice of pharmacy that he/she can so negatively comment on its practice. The commentary clearly demonstrates the individual's limited knowledge of real world practice and reads like a check list of pharmacist responsibilities from a textbook. To think that the interest in collaborative practice protocols is something the profession wishes to "suddenly" partake is but one example of this obvious naiveté.

Like other healthcare professions, the knowledge obtained in formal schooling is but a foundation upon which to build. Post-doctoral training and practice experience are essential in providing quality pharmaceutical care. Pharmacists today are not interested in "playing doctors" as he/she states; those of us extending clinical services have an expertise through which we wish to improve patient care. AT would greatly benefit from participation in a residency program, through which many real world lessons in clinical pharmacy may be learned. Over time, I believe AT will come to appreciate how much one learns through hands-on experience and how much patients do appreciate interactions with pharmacists. It is often the gratitude of patients as well as fellow members of the healthcare team that spurs those of us in the trenches to continue doing what we do.

If AT is ashamed of the pharmacy profession it is due to an obviously disjointed picture created through several academic experiences taken out of context. Hopefully practice experience will bring it into focus.

LB, PharmD, BSc(Pharm)
New Jersey, USA


To the Editors:

I think that this position from medical organization is not exclusive from the US medical organizations. We have similar position among the Spanish medical organization against Pharmaceutical Care practice. 

This reminds me the same scenario we had 30 years ago when we started implementing clinical pharmacy practice in Spanish hospitals, then we had the same opposition coming from the medical organization establishment. The difference is that we now are getting good cooperation between with scientific medical societies when we are developing specific Pharmaceutical Care programs with community pharmacists. Such societies are usually interested in cooperating with pharmacist if they perceive that the actions can help and improve patient care. 

I congratulate you for your response, but we need as pharmacists to become more visible among population in order to achieve recognition of our role as pharmacotherapy providers. I am sure that as soon as the number of community pharmacist will reach the critical amount of 20% practicing Pharmaceutical Care with patients, the battle will be won. Is the case of hospital pharmacy in developing clinical practice. There are no more than 20 or 25% of hospital pharmacists involved in clinical practice, but this number had been enough to be recognised by the society. 

This happens in all professions, we have a percentage that are excellent professionals, a percentage that are bad professionals and most of them are mediocrities. No mater if we are talking about Pharmacists, Physicians, Journalists or architects.

Joaquin Bonal, Pharmacist
Pharmaceutical Care Foundation, Spain


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