How Pharmacists Can Improve Their Relationships With Doctors Nursing Essay
The relationship between the pharmacist and doctor is a historically tenuous one. Typically, there is very little in the way of structured interaction resulting in both parties being regarded as completely autonomous bodies with the pharmacist responsible for compounding and dispensing medication and screening for errors whilst the doctor being responsible for diagnosing, prescribing and management. However as budgets become more and more strained and the focus of ill health sways towards chronic diseases requiring long term management, doctors are becoming increasingly overrun both in primary and secondary care terms. Therefore, the pharmacist is the obvious choice to try and share and alleviate this load. However, both parties must first strive to overcome their problems. The pharmacist is in a prime location to do so, as at present, as a profession, they are seeking greater responsibility and a wider variety or roles which often encroach on those of the doctor. The pharmacist should endeavour to have a clearer role specification so that the doctor understands their relative position. Also, the pharmacist should review their relationships with doctors, both in the hospital and community pharmacy setting, regarding them as peers who they can learn from and interact with, rather than just anonymous voices to consult via a phone call when an error occurs on a prescription.
In today's current economic climate, almost every avenue of government spending, none moreso than the health care system are being subjected to dramatic review and stringent rationalisation. Anything which can be deemed superfluous can and will be done away with. With this rationalisation comes a struggle between the different respective groups that comprise the health care system to justify their spending. Hospitals are being pitted against each other, doctors against doctors, pharmacists against doctors. The relationship between doctors and pharmacists has always been a rather tentative one, all too often built on a foundation of antipathy with communication between parties kept to a bare minimum. There are undoubtedly innumerable reasons for such strained relations but it is clear that the hierarchical system of the health service plays the part of protagonist. Roles within the profession of medicine are clearly demarcated ranging from intern to consultant and all in between. Similarly, the role of nurses, physiotherapists and dieticians are all clearly understood by the medical profession. However the role of the pharmacist, both within the hospital setting and community pharmacy has always been altogether more ambivalent. Pharmacists are primarily concerned with drug therapy and patients obtaining optimum benefit from drug therapy. However, to dutifully carry out this role, the pharmacist often has to impinge upon and question the authority of the doctor. This is often the only form of contact between the pharmacist and doctor thus often rendering their working relationship a difficult one.
Our present situation on the brink of financial ruination as a country has brought the health system to an impasse. It is either sink or swim. In order to cope with the future it is certain increased collaboration and concordance in all strata is required. Not only will this increased co-operation lead to a better patient outcome, numerous surveys also show that it will lead to the rationalisation of costs which is of paramount importance in a sector which annually costs the government 12 billion euro1
The Pharmacy Act 2007 recognised that the profession of Pharmacy is at a critical junction and must diversify in order to retain its integrity. Its provisions paved the way for pharmacists to do so. A recent discussion paper, published as part of the Royal Pharmaceutical Society's Pharmacy 2020 project, highlighted some of the challenges for community pharmacy. It stated:
"As the range of activities and services delivered from community pharmacies widens, the potential overlap with the work of general practice is increasing, and there is a need for formal links to be made to ensure coherence of treatment approaches and full integration of pharmacy-delivered services with those other services based in general practice." 2As of late, we are also seeing a move to expand the role of the pharmacist from the traditional responsibilities of dispensing and formulation to encompass a broad range of primary care services. It makes sense to utilise the readily available skills of these highly trained professionals which had previously lain vestigial. Pharmacists now actively engage in patient counselling on matters other than drug therapy such as smoking cessation, balanced diets as well health screening for ailments such as diabetes, high blood pressure, iron deficiency and many others. And indeed it cannot be denied that the pharmacist is centrally positioned to provide such services. In numerous surveys, the pharmacist has been placed at the top of the list as the healthcare professional in which the patient places most trust. Indeed in terms of availability, ease of access and familiarity the pharmacist is second to none. People with chronic conditions managed by medication have more contact with community pharmacists than any other healthcare professional; consequently community pharmacists are well placed to detect early changes in condition and identify at-risk patients well before they reach the hospital revolving door3.
However it is clear that by undertaking such tasks, the role of doctors and pharmacists are converging. Good communication between both parties is essential in this instance so that the doctor does not feel undermined or threatened as the pharmacist begins to share some of their responsibilities, therefore alleviating the burden on doctors. Also, pharmacists stand to gain much in terms of education on matters such as health screening and independent prescribing through the delivery of seminars from doctors. Essentially, communication is key to allow both parties to see that they stand to benefit from eachothers skills and expertise
Immediately after learning the title of our essay I began to research the topic in order to gain a basic understanding of the issue. Having gained considerable experience in ascertaining relevant information whilst writing my Junior Freshman dissertation, I had some knowledge of the best resources to use. I began my search through the Google search engine and read some articles on the topic. I found the journal 'Hospital Pharmacist' to be very useful as well as Pub Med. I also found the journal section of the library to be very helpful, and inputted terms such as 'relationship between pharmacists and doctors', 'factors affecting communication between pharmacists and doctors' and 'role of the pharmacist'. Once I felt I had a basic understanding of the topic, I spoke to a pharmacist and doctor to attain their views on the matter. I then consolidated the vast amount of information I had amassed, paring it down based on the overall view I had for my dissertation.
Reasons for difficult working relationship between pharmacists and doctors
Role of the pharmacist in chronic disease management
Pharmacists, physician prescribing errors
Collaboration between pharmacists and doctors
The Annals of Pharmacotherapy
Relationship between physicians and doctors
Role of the Pharmacist
The historical model that medical practitioners diagnose diseases and prescribe medicine while pharmacists compound and dispense medicines continues to be the expectation of most medical doctors and indeed the general public. However, the role of the pharmacist at present is a dynamic and evolving one. The traditional roles of the pharmacist include:
compounding, preparing and dispensing drugs
taking medication histories and maintaining patient drug profiles to assess patients' drug therapy for possible interactions with current medications and health conditions
counselling patients and caregivers on safe and appropriate use of drugs and the importance of complying with the prescribed drug therapy
monitoring patients to prevent or minimize the potential for adverse drug reactions4
Whilst all of the above roles are associated with drug therapy, the potential of pharmacists to play a much more central role in the health care system has recently been recognised. The PSI recently published its Pharmacy 2020 initiative which endorsed many of the proposals of the previously published Barry Report. Such proposals included health screening programmes in pharmacies, a minor ailments scheme where certain common medications are provided through pharmacies rather than G.P surgeries, and vaccination clinics in pharmacies.5 Pharmacists are the most accessible of all healthcare professionals, with no queues or appointments needed. The fact that people call into their pharmacist and take the advice may mean that a costly visit to A&E or a GP's office may be avoided. Not only does this save the patient money, it also proves cost effective for the government. The more aware the public are in terms of the skills that pharmacists have in terms of management of health care means that more people will first consult a pharmacist before immediately consulting a doctor.
Factors Affecting Effective Communication
Communication is imperative to our daily functioning, pervading through every facet of our lives. Nowhere is this more apparent than in the health care system, with so many different groups of people interlacing together with a view to providing a positive outcome for the patient. This interaction must essentially be seamless in order to provide the correct outcome for the patient; any minor glitch can have catastrophic effects. The role of the doctor and pharmacist is symbiotic and it has been established that the expertise of pharmacists when channelled through a collaborative relationship with doctors has a positive impact on patient outcomes.6 The key word here is 'collaboration', a form of communication which encompasses and relies on more factors than communication alone. In order to recognise the factors necessary for a successful working collaborative relationship, we must first decipher the reasons for disconcordance in the first place. A report published by the American Journal of Pharmaceutical Education identified the main reasons for pharmacists difficulties in communicating with other health professionals include struggles for power, poor communication, lack of trust, and an unsatisfactory communication environment. Struggles for power and autonomy are the main obstacles in communications between pharmacists and doctor.7
The profession of pharmacy is becoming more and more patient orientated and the lines between role of the traditional pharmacist and the G.P are becoming evermore obscured. As mentioned previously, pharmacists are undertaking a major role in chronic disease management of patients with ailments such as hypotension, diabetes, and asthma as well as health screening. A report carried out on the 'Influential Characteristics of Physician/Pharmacist Collaborative Relationships' showed that the most influential factor conducive to collaboration is role specification.8 By clearly defining the pharmacists role within the Primary Care context, much antagonism can be excluded as it is clear to the doctor that the pharmacist is not simply overstepping the boundary but fulfilling their duty. Once both parties recognise that they stand to gain much more by working in conjunction than being completely autonomous bodies, the collaborative relationship will come to fruition.
The same report also elicited that trustworthiness is another critical factor in collaborative relationships. Pharmacists who have worked with physicians over a period of time have had more opportunities to demonstrate their knowledge and clinical competence. As physicians become more familiar with pharmacists and achieve confidence in their abilities, trust and commitment to the relationship begin to develop. A way of achieving this and one which has witnessed vast implementation in recent years is the idea of the Primary Care Centre. By juxtaposising doctors, pharmacists, physiotherapists, and other members of the primary care network, communication between parties on a face to face basis is facilitated. As regards the dispensing of prescriptions, this makes life much easier for the pharmacist as they can obtain more prompt clarification from the doctor due to their physical proximity. Furthermore, there is scope to form a personal relationship, thus building up trust leading to an effective collaborative relationship.
Expectations of the Patient from Healthcare
The last few decades have witnessed fast economic growth and rapid urbanisation in developing countries. This along with technological advance, including revolution in information technology worldwide has led to increased demands and new expectations of patients. Now increasingly knowledgeable patients armed with the information from the media as well as guidelines developed by health planners confront physicians and pharmacists with the expectation of quality care of highest standards.9 However, the consequence of these elevated standards of the patient is that when the health care professional perceptions and patient's preferences are not concordant, it results in dissatisfaction of patients and poor outcomes of consultation.
Similarly, a sticking point for many patients is the discontinuity that exists between the seemingly conflicting care and advice delivered firstly from the doctor and secondly from the pharmacist. Upon attaining a prescription from the doctor, the patient then either immediately after or some time in the future goes to attain said prescription. It is at this point that discrepancies between the doctor and pharmacist come to light. Community pharmacists routinely screen prescriptions for potential problems, including prescribing errors, before the drugs are dispensed. They are in an ideal position to identify, record, rectify, and prevent prescribing errors.10 Whilst it is accepted that doctors will inevitably make mistakes, being human and as susceptible to error as the rest of us, the problem is the weak channels of communication that exist between the doctor and pharmacists in the event of an issue arising. Patients are often subjected to lengthy spells waiting in the pharmacy while the pharmacist tries to contact the doctor to clarify a matter. Often the doctor is uncontactable leaving the pharmacists with no choice but to ask the patient to come back later or to go with their own instinct even if it goes against what the doctor says. This is confusing and indeed irritating for the patient as essentially, the service they are receiving is below par. The aim of all healthcare professionals is to achieve the highest standards of care for all patients with a view to achieving the most positive outcomes possible for the patient, however this is only attainable when chains of communication are consistent.
Essentially what we are aiming for is a seamless approach to prescribing and patient care by the doctor and pharmacist. An effective means of achieving this is the use of drug formularies which specifies a limited list of drugs which can be prescribed to promote safe, effective and economic prescribing.11 Ideally the formulary should be drafted by a multi-disciplinary team comprising a doctor and pharmacist. By limiting the range of drugs available to be prescribed, the scope for prescribing errors is diminished whilst the scope for cost-effective prescribing is enhanced. The drug formulary also ensures that the pharmacist and doctor are on the same page so to speak. The fact that doctors often prescribe the most expensive brand name as a result of incentives provided by the pharmaceutical companies is a source of chagrin to many pharmacists. Often times the patient will refuse to accept cheaper generics as they see the doctor as being more knowledgeable than the pharmacist which makes life more difficult for the pharmacist. However when local pharmacists and doctors have an agreed formulary of first and second line drugs, such problems are eliminated. This is analogous to the situation in a hospital setting and overall it promotes greater allegiance between the pharmacist and the doctor.
In general, there is no formal provision for pharmacists to provide feedback to doctors as regards their prescribing practice. However, doctors themselves recognise that such a formal arrangement would be beneficial to them and would reduce the likelihood of prescribing errors as they are made aware of repetitive bad habits.12 If the pharmacist and doctor were to meet on a once monthly basis to discuss issues which have arisen since the last meeting, not only would the two parties be able to build a rapport outside of an often inconvenient phone call, they would also be able to minimise the need for such interventions in the future.
Chronic Disease Management
There is no area more relevant to the pharmacists today than that of the management of chronic diseases. The increase in prevalence of long-term conditions in Western societies, with the subsequent need for non-acute quality patient healthcare, has brought the issue of collaboration between health professionals to the fore. Within primary care, it has been suggested that multidisciplinary teamworking is essential to develop an integrated approach to promoting and maintaining the health of the population whilst improving service effectiveness.13 As Michael Guckian, former president of the IPU stated, "The reality is that patients with chronic diseases are losing out because pharmacists are not being utilised to their full potential within the healthcare system. Pharmacists have the experience and expert knowledge of speciality medications to facilitate preventative care and treat chronic diseases such as diabetes, asthma and cardiovascular disease".14 At present, pharmacists play a role in chronic disease management through providing education on the disease, recommendations on change of therapy, monitoring of therapy and liaison with the patients G.P.3 More and more pharmacies are undertaking health screening where rather than patients being subjected to lengthy periods in doctors waiting rooms , they can undergo routine checks such as blood glucose testing, blood pressure testing, cholesterol testing within the pharmacy when they're already there to collect their prescriptions anyways. This makes life easier on the patient, allowing them to manage their disease in one foul swoop and also eases the burden on already overworked doctors. In addition, half of all people with chronic conditions fail to take their medicines properly and 10 per cent of hospitalisations may be due to older people's inability to manage drug therapy. With their medicines expertise and accessible location, community pharmacists are in an excellent position to help limit inappropriate hospital admissions by detecting early change in conditions and identifying at risk patients and to provide medicines support for people discharged from hospital3.
Another area worthy of consideration is the role of the community pharmacy in the management of patients on anti-coagulants such as Warfarin. Under the current system, every patient must frequent the hospital ever Monday morning in order to have their INR checked. The results are then forwarded on to the individuals G.P whom if needs be, sends on any medication changes to the pharmacist. This is a very roundabout way of facing this problem, and only puts more work on the already over stretched hospital staff. It would be far more pragmatic and cost effective to allow the respective pharmacies to carry out these tests with the simple acquisition of an easy to use machine and a small fee for services rendered. This system has been piloted in a number of community pharmacies in County Durham, England and has proven to be very successful. However in order for any of these services to work, collaboration between pharmacists and doctors must be infallible as pharmacists refer patients to doctors and seek advice of the doctors on matters concerning their patients. Furthermore, in this instance, the doctors knowledge proves invaluable in educating the pharmacist as they are obviously more experienced in this area. Training evenings and seminars provided by the local G.P to pharmacies in the area on the topic of management of chronic disease would provide an opportunity for the pharmacist and doctor to interact on a basis other than the pharmacist querying a prescription over the phone, whilst allowing pharmacists to learn the necessary skills.
Within the hospital pharmacy setting, there often tends to be very little in the way of formal contact between pharmacists and doctors. Astrom and colleagues found that opportunities for collaboration occur outside formal multi-disciplinary team meetings in everyday informal interactions in wards. However such opportunistic interactions tend to exclude many vital components of successful communication, such as self-introduction with a statement of the professional's role in relation to the patient, sharing of details of any planned interventions for the patient and then discussing the point of view of the fellow professional.6 A way of overcoming such problems is to set up focus groups once or twice weekly where the pharmacist responsible for certain wards meets with the respective doctor(s) so that both parties can request comments on matters regarding the patient, discuss drug therapy and suggest any modifications. A draft of such meetings should be drawn up and made available to the patient by placing in their end of bed notes folder so that they are in the loop as regards any alterations made to their therapy. Indeed, a survey carried out on junior doctors attitudes towards pharmacists and how their interaction can be improved, 16 out of the 22 doctors surveyed expressed that they would like more personal contact with the pharmacist rather than just reading a note attached to the drug chart.12
Health care delivery is a complex multi- step process and errors are easily introduced with potentially catastrophic consequences.6 This is why communication and collaboration between doctors and pharmacists is of paramount importance. In my opinion, the role of the pharmacist specifically in terms of delivery of 'health care' is often marginalised and solely associated with the dispensing of medication. As pharmacists are regarded as being on the outermost peripherary of the health care chain, the importance of communication between them and other affiliated professionals, none moreso than doctors is often overlooked. However, as I see it, the fact that the pharmacist is in effect the last point of contact for the patient with the primary care chain, not to mention the most accessible and most regular contact means that collaboration between them and doctors is of tremendous importance. There are many factors which render communication between the pharmacist and doctor to be difficult. These include the sometimes contradictory role of the pharmacist in dispensing of prescriptions where he/she is professionally compelled to question aspects of the doctors prescribing, the nature and context of communication which takes place which is often over the phone or an ad hoc basis and the increasing overlap in roles of the pharmacists and doctor as the pharmacist plays more of a part in.
However, I do not believe any of these factors to be insurmountable, rather more easily overcome by a few simple means. The current definition of the role of the pharmacist is restrictive and outdated, but this is still the view that most doctors have of their responsibilities. As pharmacists are the ones seeking change, I think that they are the ones who need to try and change this. By drafting a clear and definitive role specification for the pharmacist encompassing new responsibilities doctors and pharmacists will have a clearer idea of their roles in relation to eachother. Another idea which I think would be beneficial to promoting better relations between both parties would be education seminars presented by pharmacists to doctors and vice versa. Pharmacists stand to learn alot from doctors about their new roles in health screening and chronic disease management and doctors could also learn alot about more effective prescribing from the pharmacist. In the community pharmacy setting, it is very rare that the pharmacist has any direct interaction with local G.P's except on an impromptu meeting. By organising informal face to face meetings with the doctor on a monthly or bi-monthly basis to discuss any matters which have arisen, both parties would benefit considerably. Primary care centres provide a pre-fabricated means of doing so and in my opinion the primary care centre shall be the core of community health care in the future. Finally, I would like to point out the invaluable role which the pharmacist has to play in our modern health care system. There is no other party so ideally situated to manage chronic diseases and alleviate the burden for sufferers of ill health. However, in order to do so, the pharmacist must undoubtedly take strides to improve their relationship with doctors.
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