The looming war between pharmacists and doctors

The looming war between pharmacists and doctors

Image: Pixabay.com

The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee

Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.

The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.

The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.

I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):

“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!

The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.

Where to from here?

The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”

The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.

Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.

We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”

The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.

The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.

A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.

But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.

There is still time

Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.

Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.

Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.

The current community pharmacy agreement expires in June 2015. There is still time.

Follow me on Twitter: @EdwinKruys

5 thoughts on “The looming war between pharmacists and doctors

  1. Really, it’s not us versus them, the focus should be on patient outcomes. Pharmacists are the drug and drug therapy experts. Don’t forget that the vast majority of community pharmacists are not owners or managers, and have zero to gain from ‘increasing script count’. Perhaps it’s about the economics of MDs and the fear over losing some of the ‘low hanging fruit’ that GPs cling onto for the easy fee for service billing. More can be accomplished by working together, as a team, for the benefit of all, but most importantly the patient; and don’t forget that the system as a whole has to change, or there will be no system at all. Most GPs are independent ‘business’ owners that bill the government and other plans for the services delivered, but the large majority of pharmacists are not independent ‘business’ owners, and don’t get paid more the increased number of scripts or other products that are dispensed; somehow you failed to address this point here, and in your piece for the Medical Post in Canada…

    Anyone can find anecdotal evidence, so using that as support for your argument is flawed. Stating “Needless to say it’s not in the interest of health consumers.” shows that you’re seeing individuals as consumers, and not patients. And with your so called logic on robotic dispensing why not say who needs a GP when we can use WebMD and other such sites to ‘diagnose’ ourselves??? And let’s be real, how many GPs actually give a vaccination? More times than not it’s the nurse that does this. Also, it’s technology that does most of the diagnostics now, and MDs have a strong reliance on this technology to do their jobs…

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  2. I think it’s important to be take a non-partisan approach to these issues. Citing anecdotal evidence a patient with a UTI handled by pharmacists went badly is has very little value and is offensive to pharmacists in general. Surely there are cases of UTI infections that do not have perfect outcomes handled by some physicians as well. Arguments should be framed with an attempt to bridge the gap and do what is best for patients – not hack down another profession secondary to your personal frustration. This “holier than thou” attitude is what already acts to alienate patients from modern medicine and practitioners.

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    • Thanks for your comment, Andrew. As outlined in this post, there are win-win solutions – like the pharmacist in general practice. I’m very interested in a non-partisan approach or solution. What did you/ your colleagues have in mind?

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  3. Anecdotes are problematic due to selection bias. We GPs see patients when things have not gone well and this may be a very small proportion of patients treated at pharmacy. The danger to patients, and it is a real one, realised both at pharmacy and in the doctor’s office – is a failure to consider the differential diagnoses. Now a doctor ought (but might not) to have a greater breadth of understanding and a better list of appropriate differentials for each presentation. Seemingly simple ailments can be life endangering. Is that right shoulder tip pain best treated with diclofenac or angioplasty (AMI)? Is that child’s conjunctivitis suitable for chloramphenicol or should they be receiving treatment in a specialist paediatric unit (Kawasaki disease)? Is that cough ripe for linctus or bronchoscopy (inhaled foreign object)? Both doctors and pharmacists are capable of failing to consider the differentials. If a doctor does so, they are likely to be subjected to significant litigation. Are pharmacists prepared to accept the same liability?

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