E-DRUG: Recognition of pharmacists as health care providers (5)
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Leo Offerhaus, Luis Justo, Atieno Ojoo
First we should thank Atieno Ojoo for bringing this article in ACCP International Clinical Pharmacist - Winter 2011-2012 to our attention.
The health workforce dynamics and quality of training is constantly changing and you do not need to be a physician to evaluate a patient-now anybody who believes he or she is a health worker should independently assess a patient to achieve specific goals that are of interest to that health professional. There is a point where those roles almost merge, like for a clinical pharmacist and a clinical pharmacologist, and that is where professionals judgement and consensus should be used decide who can do what better.
In discussing this article, it may not be useful to focus on Atieno Ojoo, but on the issues she has raised.
For about 50 years now, pharmacists noted the loss of individual touch in patient care through the evolving of large scale manufacturing. Newer medicines that cannot be assured to be delivered safely to the patient without understanding the individual patient taking the drug have emerged. Pharmacists also realized that they cannot continue collecting patient specific data to help in making decisions and make useful recommendations by proxy. Requesting the internist to gather patient specific information to help in making a useful recommendation was not only a bother to the internist/physician who are constantly short on time, but also unfair to the pharmacist and the patient. Medication history taking by pharmacists at the A&E and to those newly admitted has always yielded additional information that is useful for patient's treatment plan. This while very useful, has not become universal policy because of inadequate pharmacist workforce to fulfil that. It is not without doubt that review history taking always yields more information already gathered from primary history, and that is why specialists re-do history for patients admitted under their care.
So, I find these arguments very important and historic at the same time. Clinicians who come from backgrounds where they have not seen pharmacists getting involved in patient care are justifiably confused. I was recently involved in an international pharmaceutical care forum, and I realized that this confusion of roles is still very common in Europe outside of UK because their system of practice is still clinical pharmacist deficient. You do not need to visit that part of the world to know that. Even literature of clinical pharmacy from these parts is very limited at best. Multidisciplinary does not always mean integration, and I guess patient care there is multidisciplinary but probably not very collaborative. I also noticed that pharmacists from some parts of Europe are really struggling to get the concept right, for the fear of infringing on 'physician territory'.
I will not be surprised with the Surgeon-General kind of recognition in the US, because pharmacists there and present, and have come out powerfully to help achieve good patient outcomes.
My take on these clinical processes is as follows:
* Any healthcare professional should be able to perform patient assessment, what we should be asking is the reason for the assessment;
* Only a few pharmacists with special training should have independent prescriptive authority, and only within a specialty; more should have collaborative prescriptive authority, and especially when they are within an institution (I do that quite frequently, and the entire team is happy because they are now used to me and they know that I'm not trying to play their role, but my role)
* A pharmacist would ordinarily order, interpret, and monitor laboratory tests, when they are due, especially when it pertains to monitoring for efficacy or toxicity of frequently prescribed drugs and the tests have not been done yet by the primary physician-this is very specific!;
* Any pharmacist in a clinical environment who does not formulate a pharmaceutical care plan (pharmacy-oriented therapeutic plans) is doing a disservice to the patient, healthcare team and himself/herself;
* Every healthcare worker must play a role provide in wellness and prevention of disease; and
* A pharmacist in my hospital, together with nurses and respiratory clinical care team do patient follow ups, where he specifically draws and discusses with each patient asthma action plan, and measures indicators for control of symptoms (ED visits, AAA admissions, need to use reliever inhalers, stepping up of ICS etc).
It really depends on how you look at it. Physiotherapists, nurses, nutritionists, paramedics, pharmacists do regular patient assessments, and their objectives are different. Physicians should be asking why it took pharmacists so long to do this?
I'm in a developing country, and it seems we may catch up with some parts of the developed world who still have guarded professional territories as barriers to the patients getting the best care possible.
Timothy Panga,
Pharmacist,
Gertrude's Children's Hospital, Nairobi
tpanga@gerties.org