I work for a doctor. Before that, I worked for a dispensary of medical devices that can be sold by prescription only (and are regulated by the FDA in much the same way as drugs). As such, I’ve seen this reality from both sides: that of the prescriber who cannot sell, and the seller who cannot prescribe. My experiences on both sides of the equation have made me a believer in that separation.
I know very well how much time and money pharmaceutical companies spend flogging their product to doctors. That’s fine; their job is to make money. I just don’t see how cutting the trained, licensed physician out of the loop is a good idea. I mean, where do we draw the line? Do we draw it at the pharmacist being able to renew a Rx the patient had been taking? Maybe the doctor prescribed that drug, in that amount, for a reason, and maybe he or she wanted to see the patient again before renewing (or adjusting) the Rx. Do we draw the line at the patient being able to say, “Can I just have some Zithromax? That’s what the doctor prescribed me last time I had strep, and I feel just the same this time.”
I understand that the current, profit-driven medical profession is far from perfect. I just think giving prescriptive power - in any amount - to the pharmacist may help a few patients at the cost of hurting many, many more. And the pharma companies’ lobbying of physicians would only get ten times worse if it could be extended to the numerous, less trained and lower paid ranks of pharmacists who all of the sudden had the power to help determine the course of patients’ care.
If there is anything about the prescription that makes the pharmacist uncomfortable. An excessively large quantity of Oxycontin (usually more than 300) is enough to make almost any pharmacist unwilling to put his name on it.
There is a good example I can remember from recently, we received a prescription for a 5 year old patient for Zoloft oral solution (which is 5mg/ml), 1 teaspoon qd. One teaspoon of a 5mg/ml solution is 25mg. Zoloft has never had ANY clinical trials for any patient under 15, and 25 mg is available as an adult dosing (it comes in 25, 50, and 100mg). Even though we verified that it was intended by the MD, (or ARNP, as this case may be), not one out of 3 pharmacists who had the opportunity to fill it would. It was obviously inappropriate for the patient.
Additionally, when there are cases of direct contraindication in a medication, many RPh’s will require written documentation that the MD is aware and is accepting all liability in the event of something resulting from that contraindication. It just boils down to the fact that pharmacists have professional discretion in what they feel is appropriate because a dispensing incident can result in the loss of their license.
They are not just tools of the physician because they are equally liable, and also have the medical obligation to be concerned with the best interests of the patient.
I think that the thing that’s missing here is that most pharmacists wouldn’t even want the responsibility because the truth is they don’t have the laboratory resources to be doing that kind of prescribing. There is a very real danger in prescribing the wrong type of antibiotics, as QtM has pointed out, and it’s not something that pharmacists are necessarily willing to risk their license for. There are all kinds of things that they do regularly diagnose with OTC meds. Head lice, boils, decongestants, allergic reactions, wound care, poison ivy, the list goes on.
I don’t think anyone is advocating “cutting the trained, licensed physician out of the loop”, because as I have said before, in many states pharmacists do have limited prescribing power. For instance, in many patients who are taking Coumadin, an anti-coagulant, the pharmacy performs the INR and adjusts the patients dosing based on the results of the INR, no physician consultation required. They do this to fast-track the patient care, so that rather than having a standing once a month appointment to get all this done at the Dr’s office, their levels can be checked constantly and adjusted as necessary. Do you feel that a pharmacist isn’t properly trained to be doing this?
You do realize that those pharmaceutical reps do visit the pharmacies, and we consider them pretty bottom of the barrel as far as important people go. What is this logical end result that you feel is inevitable if “pharmacists were given the power to help determin the course of a patient’s care”? They already do have the power to determine the course of a patient’s care. They are healthcare providers. They go to school for a very, very long time, and they aren’t significantly less trained, and I’d say that at least as far as pharmacology goes, they know more than many doctors do. But that’s their job, to know as much about pharmacology as it is possible to know so they can be the “last line of defense” before a patient receives a medication.
I don’t understand where this idea that pharmacists get paid per prescription, or get paid more money for more expensive medications came from. This simply isn’t true, and if it were the case, I wouldn’t spend all my time trying to reverse the effects of the pharmaceutical lobby and get your third-tier medications changed to first-tier generics because you aren’t interested in paying $50 a month for Ambien CR.
So I’ll reiterate: what exactly is this doomsday scenario that you envision if pharmacists had the ability to prescribe and dispense certain medications?
Note that we’re not talking about allowing pharmacists to prescribe all medications. Nobody is talking about opening the floodgates, here.
-foxy
BTW, I see a drug rep maybe once or twice a year, when I go to a conference. They don’t visit me in my practice. I grab all the free pens I can when I see them, because my nurses like them better than the government-issued pens they otherwise have to use.
Sometimes I get sticky notes, but mostly not.
Once every 3 or 4 years, I go to a medical education dinner that’s partly underwritten by drug reps, or so I’m told.
I prescribe from a formulary, so drug rep pressure wouldn’t change my habits. And I also sit on the committee that writes the formulary, and I get my data on the drugs we’re considering adding from the academic sources, not the drug companies.
I won’t say the pharmaceutical industry lobbying arm has no impact on my practice, but it’s pretty damn minimal. Congress should be so minimally influenced by special interests.
I can believe it. But I believe that if the status quo - where pharmacists have no direct power to get one medication rather than another into a patient’s hands - were changed, those reps wold be far more numerous and pushy.
(emphasis mine)
That’s as it should be. When I go to a pharmacy to have a prescription filled, my expectation of the pharmacist is that they review the prescription for any obvious errors, check against my other prescriptions for any interactions the doctor may have overlooked, dispense my medication and give me instructions on its use. If they were to tell me, “you know there’s a generic for this that would cost you $5 instead of $30,” I would consider that a bonus, but I don’t really expect their input otherwise. They haven’t examined me, haven’t been privy to any of my lab results…why would I?
No, pharmacists don’t get paid per prescription. Pharmacies, however, do. They’re a for-profit business whose sole, or primary, source of income is the mark-up on the medicines they sell me. I was accused upthread of having a knee-jerk reaction to this, but it stands: when I go to buy a car or a DVD player, I expect the store to try and sell me the item that they stand to make the most money on, and I expect myself to be looking for the purchase that best suits my needs. When I go to buy medicine, I don’t want to have to fight that fight. The stakes are higher and my knowledge isn’t as deep. It’s already a flawed system, since doctors are under bombardment from pharma companies, but I don’t see how extending prescriptive power to pharmacies improves it. If anything, it makes the situation worse, for the reasons I entailed in my last post.
“Doomsday scenario” is your term, not mine.
I’ll concede that extending that ability to pharmacists in some situations, meaning certain medications for certain patients, would probably help the patient while involving a minimum of risk. But if we aren’t talking about opening the floodgates, what are we talking about? I’m not comfortable with non-doctors prescribing or dispensing, antibiotics or most psychoactive drugs, just to name two. Maybe I’m just comfortable with the line being drawn where it is because I can’t think of where else we’d draw it.
Exactly, but we aren’t talking about a situation where you go to the pharmacy, hand them a prescription, and the pharmacist comes over to counsel you about changing your medication to something completely different because they feel it would work better. We’re talking about a situation where you go to the pharmacy for the purpose of fixing some symptom or infection you have, and enabling the pharmacist to give you a dose of Pyridium to minimize the pain of your UTI on a Saturday until you can make it in to see the doctor on Monday.
You’re right, but that’s not what you said. What you actually said was:
Implying that the Pharmacist stands to receive some direct monetary gain from pushing medication into your hands. I’m merely arguing that this isn’t the case, and that the conflict of interest is minimal at best. The point is that allowing pharmacists limited capacity to prescribe medications does not mean that you have to seek medical treatment from them. They are not taking the place of your doctor, they’re supplementing them.
Then I suppose you are also uncomfortable seeing an ARNP, or a PA for your common cold because they are also non-doctors with prescribing power. Arguably they have significantly less knowledge about pharmacology than even your worst pharmacist. There isn’t really as clear a line as you might think separating these situations.
-foxy
That’s exactly the sort of policy I would support in my campaign to conquer the Earth.
Not AFTER I conquer the Earth, mind you. Then I’d be invested in keeping things working right. But before, to screw up pretty much every damn industrialized country … oh, yeah. Endless unprescribed drugs, $35/hour minimum wage, and free holodecks for everyone.
If Pharmacies got that kind of power,the bribery would follow. But, they do have much more accessible hours than doctors do. How often do sickness arrive at inconvenient times,late night,holidays etc.?
Question (and hijack I suppose): Do you think that your experience is typical?
The reason I ask* is that my doctor friends are always telling me about drug reps schmoozing them up. Not in a, “hey I need to prescribe this drug more! It’s a miracle!” kind of way, but more in a “I’m going to get a free dinner and get drunk on some pharma rep’s dime.”
Just wondering if you think your experience approximates the typical level of the doctor - drug rep interaction. And other Dr. Dopers, feel free to chime in.
I am not a Medical Doctor and I have never had a companion on the TARDIS who was a pharma rep, so I’m interested.
Why would it be any more likely that an individual would bribe a pharmacist and not a doctor? You could just as easily bribe a pharmacist to just give you drugs as it is.
What about those pharmacists who own their own business and aren’t working for the chain retails? Also, as someone pointed out, for those without health insurance, they might be tempted to consult a pharmacist for all the things they really ought to see a GP for.
I came from the belief that the greatest reason that there was a separation between the prescriber and the dispenser was specifically to circumvent the conflict of interest to the public of having a person who might be tempted to tell you that you have every problem under the sun just to sell you more magic health elixir. I hear in some countries like Japan, that there is no such division and I’d love to find out how that’s working out over there.
And just to declare my stance, please understand I would support very limited prescription power and feel pharmacists are sorely looked down upon by the general public for all the wrong reasons, but even I’d have to say this would have to be for very limited cases (partly for the patient’s interest, partly for the pharmacist’s interest) and I wouldn’t mind the status quo, either.
I think the only way there is a conflict of interest would be in situations of independent pharmacies, like you mentioned. But as I’ve stated before, there are states that currently allow pharmacist prescribing (Florida being one of them), and what’s being allowed is not exactly bank-breaking medications. We’re talking about some higher strength NSAIDS; 600 & 800 mg IBU, or Naproxen, some topical steroid creams. We’re really talking about medications that cost wholesale between $.50 and $5. I couldn’t find a list of exactly the allowed medications, but the name of the law is called the “Florida Self-Care Consulting Law”. The only articles I can find are pay-journals.
I don’t believe that the whole “tempted to consult a pharmacist for things they ought to be seeing a doctor for” because the reality is that I don’t see a pharmacist risking his license to treat something that they know they aren’t familiar with. It happens all the time with people who come asking for consultation for OTC medication; as I’ve said before, pharmacists are trained medical professionals who are able to recognize when a problem warrants an office visit.
Pharmacist prescribing was utilized in many states before Plan-B went OTC, you simply consulted with the pharmacist, filled out some paperwork, and got it without necessitating a prescription. This would be a similar situation only instead of saying “The condom broke”, it would be “I have a rash that I got from working outside”, and if the pharmacist felt comfortable issuing something for it rather than saying “I think you should see a doctor,” they would.
I really wish I could find the list of what medications Florida has allowed so that the debate here can be narrowed to whether or not pharmacist prescribing should be allowed at all, and not just the knee-jerk reactions of all the things they shouldn’t be prescribing.
That’s an understandable fear without a simple solution (pharmacist’s right of conscience versus patient’s semi-right to get their legally prescribed medicine). But people fail to consider that a Doctor, Nurse Practitioner, or Physician’s Assistent (here in Ohio) don’t have to prescribe birth control (as far as I know) or abortifacients. There’s no law (at least, not that I’m aware of here in Ohio) requiring them to do so. So why the double standard for a pharmacist versus a prescriber? (Which is probably better targetted at another thread so we don’t go too off topic).
