E-DRUG: pharmacy drivers, Trust and Ethics (cont)
-------------------------------------------------
Hi all
Mariam has certainly sparked some interesting debate on the
issue of "face to face" counselling. While we have veered from trust
to patient rights, from training of drivers to concordance
(asyoulikeit - WB will have to teach us to pronounce that with the
right accent), I think an important dimension has been missed.
The SA Pharmacy Council (our statutory body) has chosen to use two
separate mechanisms with which to control the practice of the
profession. The first can be regarded as the "aspirational" side - a
series of publications on Good Pharmacy Practice in various settings
(hospital, community practice etc). The second, a survivor of the
previous set of Rules which complement the local Pharmacy Act,
is a dismal listing of possible misdemeanours. The relevant section
of the Act states that "the council may from time to time make rules
specifying the acts of omissions in respect of which the council may
take disciplinary action". Naturally the Council also reserves the
right to deal with any complaint, charge or allegation and not be
restricted to those specified in the rules. The Rules in question are
prefaced by a statement that "the undermentioned acts or omissions
shall be deemed to be unethical or unprofessional conduct". It would
therefore seem appropriate that the Good Pharmacy Practice guidelines
would seek to advance the profession, and would include aspects which
cannot yet be attained, but which should be aimed for - the "nice to
have". It would however, clearly distinguish such aspects from the
minimal standards for safe practice - the "have to have". The
so-called "Ethical Rules" would then be expected to be clear and
unambiguous statements of the "have to have", worded in reverse - the
list of acts of omissions which would be "unethical or unprofessional
conduct". Let's revisit the wording proposed in the amendment (the
current wording ends after para (a)):
"Failure in the interest of the patient to:-
(a) furnish advice or information for the safe and effective use of
medicines supplied by him/her.
(b) counsel personally a patient or the person to whom the medicine is
supplied on behalf of the patient on any matter which in the
pharmacist's judgement, will enhance or optimise the medicine therapy
prescribed:
Provided that such counselling should be done face to face."
The first paragraph is the general rule, but does not specify how
that information is to be furnished. The second is amplified by the
statement about the "counselling" being done "face to face". When the
practicality of the situation is questioned, the reply is that such
counselling is only obligatory when, "in the pharmacist's judgement",
some information has to be conveyed which "will enhance the medicine
therapy".
What I think has been missing from the debate is whether or not this
is good law, not whether or not counselling is necessary, or who
should do it. In a perfect world, everyone would be counselled (by
Billy's standard) whenever receiving medicine. That counselling would
occur "face to face", so that all non-verbal clues could be detected
and acted upon. The counselling would also be done by someone
adequately trained (pharmacist or suitable registered support
personnel). However, if we go back to Rina's comments, we see that
there are many situations in pharmacy where "face to
face" contact is not possible. Let us imagine that such a situation
is detected by the Council, and disciplinary action is initiated.
Would it be sufficient defence for the pharmacist to claim that "in
his/her judgment" no additional information was required in that
particular case?
In South Africa, as in many developing countries, we face a shortage
of trained personnel, as well as maldistribution of those we do have
(see http://www.hst.org.za/sahr/98/Pharmacy/ for a report produced by the
Pharmacy Council on this issue). In the public sector post-basic
trained pharmacists' assistants will practise under indirect
supervision in primary care settings. In the private sector, the use
of technology might be the answer. Under the current suggestion,
would it be unethical for a pharmacist to supply sophisticated
antibiotics to the Intensive Care Unit without counselling the
care-giver (nurse, or hospital porter who transports the medicine to
the ward)? Or would the excuse have to be that no additional
information was warranted? Would a pharmacist practising in a
courier-delivery (mail order) system, who had communicated with the
patient by telephone and in writing, be considered unprofessional?
I'm not convinced that any disciplinary action based on the suggested
wording will succeed. But what I do agree with, is that face to face
counselling should be included in the Good Pharmacy Practice
guidelines as an aspirational goal.
South Africa will always be an intriguing mix - in the public sector
we have to strive to achieve a minimum standard. As a taster, there
are currently 15 state hospitals in the Free State province (pop 2.6mill)
which have no pharmacist at all. In our well-funded fee-for-service
private sector, we see almost every technological tweak possible. As
a final teaser - consider the following: in proposing a model for
for licensing practitioners in Internet-based telemedicine (see
http://www.fsmb.org/telemed.htm), the Federation of State Medical Boards
of the United States made the following statement:
"Telemedicine demonstration projects have clearly shown that current
technology will allow a physician in a distant state to conduct
"face-to-face" consultations with a patient in another state".
So - a good idea, well backed by theory, evidence and sentiment. But good law?
I have my doubts.
regards
Andy
Email: agray@pixie.udw.ac.za [manually added by moderator; WB]
--
Send mail for the `E-Drug' conference to `e-drug@usa.healthnet.org'.
Mail administrative requests to `majordomo@usa.healthnet.org'.
For additional assistance, send mail to: `owner-e-drug@usa.healthnet.org'.