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Medical Forum / General / Pharmacy / September 2005Is retail pharmacy on a collision course with reality?
From what I gather, acceptance into pharmacy school today has become almost as difficult as acceptance into medical school has been. Pharmacists are now prepared by their education to think and act clinically. Yet, from what I hear is happening in the field (I am not longer in retail practice myself), little has changed in the working conditions and day-to-day expectations of the society (top management, regulators, the public) regarding pharmacists. The technology may be better now, but the assembly-line paradigm is still in place, and retail pharmacists may not have any prospect for having medication management as their actual full time job as suggested by their own education various sources of officialdom. What is going to happen next? To what extent will present and future generations of pharmacy graduates, who have endured a highly competitive and highly sophisticated academic experience as pharmacy students, interns, Pharm D. candidates, and then, perhaps, pharmacy residents, continue to accept the status quo in community (retail) pharmacy practice? To what extent will they start to demand that they be allowed to practice pharmacy only, and not be saddled with third-party ombudsmanship or data entry servitude? I think I have your answer... The day that will happen will be the day most Pharm Ds wake up and stop working for the big retail chains. I would like to see every pharmacist in every retail chain in America stand up to those coroporate goons. Pharmacists should be running their own pharmacies with disease state management centers and such, and they should see patients by appointment, and be reimbursed for doing so! The day this happens for me is day 1 after my graduation in 2007. I will not put up with the status quo... I will do the job I am trained for... TAKING CARE OF PATIENTS. Many of my class mates stand with me on this issue. Nan, Good luck! I find it difficult to feed my family, pay bills and purchase various necessities of life on reimbursements for disease state management, be it private pay or public. As more and more health care is financed by third parties, I see the trend only worsening. C U L8R! Wiz <{;-) >I think I have your answer... > [quoted text clipped - 11 lines] > >. Paul, Myself and many other pharmacy grads from the late 1970s and early 1980s were asking these very questions years ago. If I remember correctly, you are also a graduate from the same era. We as practitioners have not been allowed to use those skills we dutifully learned 20 plus years or so ago, and we have seen the regulatory requirements increase, as well as expectations from public and private sectors. This does not bode well for "future pharmacists", in my opinion. I feel abandoned by those regulatory boards that allow a "PA-C" (Physicians Assistant-Certified) and NP (Nurse Practioners) to advance in their professional duties and responsibilties, meaning prescribing privileges. The ONE group of professionals, with the skill set and the knowledge base to handle prescribing medications, has largely been left out of the game...pharmacists. The answer??? I don't know, but a start would be for pharmacists to "Just Say No" to filling RXs written by these "ancillary personnel"! C U L8R! Wiz <{;-) when there is a will there is a way. Creative financial solutions will be as helpful as the creative change in pharmacy education. Have patient's join your pharmacy service, by the year whether they use it or not. Kind of like insurance. For a set amount you will provide these services no matter how many RX's they have. They can pay by the month, maybe you can even have folks prepay by payroll deduction. Wiz, Correct, I'm from that era, but I wasn't asking this particular question then, because then, PharmD was not the basic degree, and, for example, in my home state of Massachusetts, pharmacy was still legally considered a trade; it was lumped in with barbers, pipefitters, and hairdressers. But, in 2003, pharmacy was taken out of the Massachusetts Registration Division and moved into the Department of Public Health. Now we also have Medicare Part D and the mandate for reimbursible medication management services. My question 20 years ago was why I couldn't use my skills, but my question today is what is going to happen when this truly new breed of pharmacy graduates hits the bricks. You and I graduated with the promise of clinical pharmacy in our future. But these folks are being trained as if clinical pharmacy was the norm, and community pharmacy practice doesn't appear to be any different in form than it was 30 to 50 years ago. I'm seeking to know if whether or not there is going to be a general refusal, this time, of pharmacists to go into retail, because now, it runs totally contrary to their training and the competition they had to survive to get to that degree and license. Would a medical doctor stand being given a clerk's duties? That is the reaction I'm expecting. No, this is a new question. In 1976, I was ready to tolerate the rough and tumble. I'm asking if this generation will or not. I don't think they will. Paul > Paul, > [quoted text clipped - 20 lines] > C U L8R! > Wiz <{;-) I am thrilled that this discussion is taking place. Again, I have to reaffirm that we pharmacists are the ones that must change our profession. It can only be done as a collective effort of many, many people. I have a question for the older pharmacists who have been practicing for 10 or 20 plus years... why do so many of us refuse to help push our boundries? Is it because we have nice salaries and we don't want to mess things up? Are we too comfortable in our ever-shrinking niche? A good start would be as simple as pharmacists in retail settings asking or demanding that consultation offices be installed, and that another pharmacist is on duty to assist. Then pharmacists can really counsel and start to provide services. Who will reimburse us? Well, until wallgreens figures out a way to charge patients for our services, Walgreens should reimburse us. If we "asked" for these changes how could they have any choice but to accomidate us? We are the people who make or break the bank for these chains. Why should we let the corporate world dictate how and when and to what degree we practice? I had an interesting conversation with a physician two weeks ago. He said that as he was growing up (he is in his 50s) there were three types of professionals... Physicians, Pharmacists, and Lawyers. He said that today most physicians don't consider pharmacists "professionals" because we don't use our skill set and we don't act professionally. He said, " How can I seriously consider a pharmacist a professional if they put themselves behind a drive through window? How demeaning is that!" His point was that we have skills, but the majority of us do not use them. We are also the ones in charge of how we practice. If we change the profession for the better we will gain respect and acceptance among the rest of the medical community... and who knows, we may have pharmacy practicioners! > Paul, > [quoted text clipped - 17 lines] > pharmacists to "Just Say No" to filling RXs written by > these "ancillary personnel"! excuse me here...but HOW do you intend to determine WHAT pharmaceutical is appropriate in each situation?? have you also been trained in exam and diagnosis??can you do pelvic exams and look at organisms under a microscope? are you going to do strep cultures etc to find the bacterial infections of the throat?? course not...YOUR expertise IS in the pharmacology end of medicine...and no one is questioning that expertise.. but PLEASE...suggesting that WE NPs and PAs are ancillary personnel is not only insulting ..it is down right ludicrous... one CANNOT provide adequate patient assessment from behind a pharmacy counter... do YOUR job...and I will do MINE...neither of us can practice without the skills of the other... > C U L8R! > Wiz <{;-) Hey, Got a news flash for you...in pharmacy school WE DO THAT! I suggest you examine the requirements for a degree in pharmacy, especially if you intend on haunting a pharmacy news group. Microsocopes, cultures, diagnosis...we did them all, and that was back in the late 1970s. To imply that NPs and PA-Cs are somehow more qualified than a RPh to choose appropriate treament modalities illustrates my meaning better than any post to a newsgroup. While NPs and PA-Cs can and should be utilized in some situations, I for one pharmacist am TIRED of fixing the screw-ups due to ancillary personnel now given the privileges once held in enough esteem to reserve them for those that WERE trained in prescribing. C U L8R! Wiz <{;-) >> Paul, >> [quoted text clipped - 41 lines] > >. If I could add something here, not being either a NP or PA nor a RPh.......... How about a team approach ( I know it is done sometimes in some places but not to the degree that it is accepted practice). By team approach I mean this...... The Docs, the PA-C's and the Licensed NP's do the patient assessment and diagnosis and then after consultation about the diagnosis, the RPh's make the determination of the best and most appropriate medication regimens. Wow, is that so hard? I was raised in a medical family, I am a volly medic, my dad is a double boarded in Internal Medicine and Hematology, my mom is a Psych RN, I have a sister who is a critical care RN and a brother who is a Psychiatrist..... yet another brother that has his MHA and is deputy administrator of a non profit Catholic hospital, I was also a certified substance abuse counselor. I only mention these things to qualify my opinion. Frankly the good pharmacists know the best medication regimens for different patients who have polypharmacy issues and multiple medical problems. So how about the medical professionals diagnosis the disease and treatment and when treatment with medication (s) is needed, the pharmacist comes in with the best regimen of medical intervention! Makes sense to me, unless I am just a total idiot. If so, I will be flamed appropriately I am sure.  SignaturePatrick Patrick H. Mason MS, OHST, EMT-I A delusion shared by many is a culture; shared by some is a cult; shared by 2 is love; but a delusion held by one is psychosis. > Hey, > Got a news flash for you...in pharmacy school WE DO THAT! [quoted text clipped - 58 lines] > > > >. > If I could add something here, not being either a NP or PA nor > a RPh.......... > > How about a team approach ( I know it is done sometimes in some > places but not to the degree that it is accepted practice). Patrick... I believe I was saying the same thing BUT...I still want this pharmacist to tell me HOW he intends to decide WHAT med to pick?? sure he learned how to look under a microscope...but howabout getting the SPECIMEN to put under it?? that was my point pharmacists are NOT trained in assessment and diagnosing..and unless things have changed...nor do they have the skills to do a pelvic,, listen to lungs etc etc... again..calling an entire population of highly trained professional healthcare providers "ancillary personnel" is a huge...and totally unlearned insult.. > By team approach I mean this...... The Docs, the PA-C's and the > Licensed NP's do the patient assessment and diagnosis and then [quoted text clipped - 86 lines] >> > >> >. What I would like to see is a doc calling up a pharmacist and saying..... hey I have this 75 y/o lady on HCTZ and Atenolol along with Amiodorone due to her chronic A-Fib and difficult to manage hypertension, I have admitted her to the local tiny community hospital in our town of 23K people for Tracheitis and it looks like she has cultured up legionella.... I have been treating her with IV vancomycin but was wondering what is the latest on your end for this bacterium? Should I add a floxin to the mix or is there something newer that you have studied that is better for this gram neg. infection. Just a thought, and actually a pretty likely scenario in my community. We don't have intensivists at the local Hospital in my town. In addition to my regular job I work at the hospital ER as a medic.... they call us ER Techs, we do blood draws, give injections, ABGs, Vitals and Triage. But I pay attention to a lot that goes on, not enough internists around, lots of family practitioners. The local practices have some great PAs and NPs working for them, but when a patient is in the hospital that is where their practice ends. They seem to be limited at most hospitals to office practice only, the hospitals won't give them privileges with their Docs offices. Anyway, just my humble, non professional, paramedic type rants. SignaturePatrick Patrick H. Mason MS, OHST, EMT-I A delusion shared by many is a culture; shared by some is a cult; shared by 2 is love; but a delusion held by one is psychosis. > > > If I could add something here, not being either a NP or PA nor [quoted text clipped - 109 lines] > >> > > >> >. > What I would like to see is a doc calling up a pharmacist and saying..... > hey I have this 75 y/o lady on HCTZ and Atenolol along with [quoted text clipped - 6 lines] > something newer that you have studied that is better for this > gram neg. infection. Patrick... I agree that would be a good scenerio...all the best for patient care.. again....you did not do the diagnosing...but the diagnoser called upon you to use YOUR expertise,,which is pharmacy > Just a thought, and actually a pretty likely scenario in my community. > [quoted text clipped - 8 lines] > practice only, the hospitals won't give them privileges with their Docs > offices. Actually...many many NPs and some PAS do have hospital priviliges!!! Depends upon the area,,and the speciality.. For instance..in NYC a group of Neonatal NPs literally run the Neonatal ICU ...at Columbia Pres if I recall correctly...they have been written up a lot in the media too.. those that do have hospital privileges CAN admit,,follow ..discharge etc patients they have followed in the office... others have attained a status similar to medical residents....tho truthfully..we all know how overworked and underexperienced residents are!! Since laws have been passed to limit the number of hours they can "work" (thank god!!)...many advanced practice clinicians are filling in the gap.. > Anyway, just my humble, non professional, paramedic type rants. > [quoted text clipped - 121 lines] >> >> > >> >> >. > Hey, > Got a news flash for you...in pharmacy school WE DO THAT! oh...?? in pharmacy school you learn to do pelvic exams?? hmmm...news to me... > I suggest you examine the requirements for a degree in > pharmacy, especially if you intend on haunting a pharmacy > news group. sorry ....saw the NP slur and had to jump in... Microsocopes, cultures, diagnosis...we did > them all, and that was back in the late 1970s. again...did you OBTAIN the specimens?? didn't think so... that was my point To imply > that NPs and PA-Cs are somehow more qualified than a RPh > to choose appropriate treament modalities illustrates my > meaning better than any post to a newsgroup. "choosing appropriate treatment modalities" must start with patient exam and assessment...first you must determine a clue about etiology.. > While NPs and PA-Cs can and should be utilized in some > situations, I for one pharmacist am TIRED of fixing the > screw-ups due to ancillary personnel now given the > privileges once held in enough esteem to reserve them for > those that WERE trained in prescribing. EXCUSE me?? YOU were NOT trained in prescribing!! I on the other hand...was... do YOU have a DEA number (of your own?) and a license to prescribe?? don't think so.. ancillary personnel?? NPs and PAS are not sounds like you are being threatened by a newer group of prescribers.. and ...BTW..it is YOUR job to catch the mistakes of the prescribers...that IS YOUR job...and personally luckily any pharmacist I have ever worked with did not have your know everything attitude once more...pharmacists cannot prescribe ...because they do not have the assessment and diagnostic skills ... simple as that > C U L8R! > Wiz <{;-) [quoted text clipped - 45 lines] >> >>. >> Hey, >> Got a news flash for you...in pharmacy school WE DO THAT! [quoted text clipped - 49 lines] > >simple as that No, not simple as that! The ONLY reason PAs and NPs were "granted" prescribing privileges was heavy lobbying of the various regulatory boards. If I stepped on toes, so be it. It is NOT my job to clean up YOUR mistakes...it IS my job to make certain the medication is being prescribed properly for the right patient, the right dosage, and the right time frame. Yes, I get a bit sensitive to others that their only reason for existence as a "profession" was a cost-saving measure by insurance companies. NPs and PA-Cs have a better lobby in governing circles. Give a choice of medications to the pharmacist, let them choose which med to use for a particular patient. Luckily, most of the NPs and PA-Cs I work around have somewhat of a teamwork attitude. As for a team approach...that is another of those ivory tower ideas we were introduced to in pharmacy school. Which reminds me...yes, we were instructed how to obtain cultures, including growing them, as well as take blood sugar, blood pressure, digitalis levels, CHEM 25s, etc. I have no doubt that contempory pharmacy education is just as rigorous as anything in NP or PA-C. C U L8R! Wiz <{;-) >> Wiz <{;-) >> [quoted text clipped - 46 lines] > >. >>> Hey, >>> Got a news flash for you...in pharmacy school WE DO THAT! [quoted text clipped - 55 lines] > "granted" prescribing privileges was heavy lobbying of the > various regulatory boards. The reason we were granted prescribing "privileges" is because in the US more than 65% of primary care medicine is given by NP and PAs.....safely..I may add.. the "regulatory boards" did extensive study of our prescribing practices..and deemed it safe and effacacious (sp?) to allow us independent prescribing...including ,,,in most states now..controlled substance priviliges and a DEA number this was NOT done based upon our "lobbies"...but based upon the continued safe and effective decision making studied...if you think it is EASY to obtain prescribing practices when not a physician...try it If I stepped on toes, so be it. > It is NOT my job to clean up YOUR mistakes...it IS my job > to make certain the medication is being prescribed properly > for the right patient, the right dosage, and the right time > frame. Yes...that IS your job...after others have determined WHAT the medication should be Yes, I get a bit sensitive to others that their only > reason for existence as a "profession" was a cost-saving > measure by insurance companies. actually..the insurance companies had NOTHING to do with our obtaining prescriptive privileges!! NPs and PA-Cs have a better > lobby in governing circles. Give a choice of medications > to the pharmacist, let them choose which med to use for a > particular patient. ahhh...so changing the story are ya?? Why should I ..a licensed professional with my own knowledge base and diagnostic skills...first do the evaluation,,determine the problem..then let ANOTHER professional determine "which choice" of med to use?? as a licensed professional NP and PAs are totally and legally responsible for the entire gamut of care ...including..of course..what med is appropriate... I do count on the pharmacist for advice and guidance when I ask for it...I do believe in the team approach..but sorry...YOU will not get to choose the med Luckily, most of the NPs and PA-Cs I > work around have somewhat of a teamwork attitude. > As for a team approach...that is another of those ivory tower [quoted text clipped - 4 lines] > doubt that contempory pharmacy education is just as rigorous > as anything in NP or PA-C. you continue to ignore my point...YOUR profession is not trained in patient exam,,assessment..diagnostics..etc...oh..sorry..you know how to take blood pressures.. again I ask if you were trained in pelvic exams,,listening to lungs and hearts..and how and what your findings indicate.. hey...I don't know WHY you are dissing the entire NP and PA profession...simply because we write the scripts that you fill...you chose one road..we chose another..we both are there to take care of the patient..not to have turf wars.. I always had excellent rapport with the pharmacists in our clinics..and counted on them for advice and info...as a group pharmacists are great at teaching..patient education and yes..in catching mistakes... is there some reason you have it in for NP and PAs?? better get used to hating clinical psychologists next...as they are getting prescriptive priviliges too(and not the MD shrink types).. > C U L8R! > Wiz <{;-) [quoted text clipped - 53 lines] >> >>. A lot of improvement in prescribing could be had by having a community selected formulary system. We had one at Sinai Hospital of Detroit in the 70's and before. The formulary system was composed of expert doctors in their fields with other personel including the Pharmacists as advisers. We (I am a Pharmacist) usually did some literature research and provided reports on the drugs that came up for review. It was a rare day that drug salesmen were allowed in the hospital and we did not allow drug samples. We had drug fairs where ALL drug salesmen could register and display their "new wonder drugs" and answer questions. Thus the hospital personnel were not exposed to the one drug of a particular drug salesman and could see the various alternative treatments that were on the market. This could be done in a community WHEN all the Doctors and Pharmacists decide to work together instead of seeing who can make the most money. For instance a lot of people, if not most, in rural Mississippi have no health insurance and no coverage for prescription drugs. Yet I used to see doctors start people on drugs like Celebrex that they could not afford to purchase. They usually did not fill the prescriptions unless they had Medicaid. There was a lot of use of so-called branded generics. Drugs like a copy of an antihistamine with pseudoephedrine but with a brand name like "AlaFed" for Alabama rebranded decongestant-antihistamine. Althought these worked OK, as would the OTC versions, they might cost the poor patient $30 or $40 for a supply. A town like New Orleans needs a different formulary than some of the towns I have been in where every other car is a BMW. Some of the poor in NO could not leave the city as they didn't have two pennies to rub together or a car. The local health group could collect lab results and do their own drug studies to determine the most cost effective drugs and decide what drugs to initially prescribe to treat a particular condition. This would include all members of the healthcare team. I am controlled on warfarin by a nurse. I don't see the doctor. If the lab results come back greatly out of range the Coumadin Clinic nurse would contact the doctor and change the warfarin dose. Years ago at Sinai we tried a program where the Pharmacist visited with the patients before they had their Rxs filled in the clinic pharmacy. He asked them if they had any problems with their medications, how they were doing, etc. Then he OKed refills on their existing Rxs if everything seemed OK. This program, althought popular enought, was stopped as it did not generate any income for the hospital. Today prehaps a Pharmacist could be paid for doing it by the insurance companies. If either Canada or Cuba spent the money America spent on health care their results would be better than ours. We allowed the insurance companies, drug companies, and the federal and State governments to become our doctors and to decide what kinds of treatment will be provided for sick individuals. Fraud runs wild in the whole system and there are hundred of kinds of insurance plans to deal with. just an FYI, the way the system is supposed to work regarding the current level of training of PharmD is that those individuals that specialize in diagnosis, diagnose. those that specialize in therapy, provide therapy. there is no need to carry on a flame war, NP's and PA-C's provide a vital service to medicine... often doing the work that the MD doesn't feel like. and without appreciation. I am from TWO of the most under-appreciated professions. I am a Paramedic and a PharmD student. few pharmacist's will claim to be diagnosticians, but we do in fact learn many diagnostic procedures, and in many places (especially in hospitals) do order the tests necessary to continue therapy. but the fact is that pharmD is 4 years of Graduate school with an additional (optional at this time) residency up to 4 years. this gives the pharmacist special insite into adjusting drug regimens. I don't think that PA-C's or NP's should loose their prescribing athority, but I do think that pharmacists should have prescribing athority, at least in a limited capacity. and ALL prescribers, MD PA NP PharmD, need to be ready to work together for the PATIENT"S good not just our own... IMHO, Eric currently, the US spends more than twice per capita on healthcare than any other country in the world, but we are ranked 15th out of the top 25 industrialized countries in care received (according to a lecture I attended yesterday) just an FYI, the way the system is supposed to work regarding the current level of training of PharmD is that those individuals that specialize in diagnosis, diagnose. those that specialize in therapy, provide therapy. there is no need to carry on a flame war, NP's and PA-C's provide a vital service to medicine... often doing the work that the MD doesn't feel like. and without appreciation. I am from TWO of the most under-appreciated professions. I am a Paramedic and a PharmD student. few pharmacist's will claim to be diagnosticians, but we do in fact learn many diagnostic procedures, and in many places (especially in hospitals) do order the tests necessary to continue therapy. but the fact is that pharmD is 4 years of Graduate school with an additional (optional at this time) residency up to 4 years. this gives the pharmacist special insite into adjusting drug regimens. I don't think that PA-C's or NP's should loose their prescribing athority, but I do think that pharmacists should have prescribing athority, at least in a limited capacity. and ALL prescribers, MD PA NP PharmD, need to be ready to work together for the PATIENT"S good not just our own... IMHO, Eric Reply and as far as PA's and NP's having a strong lobby, that is good for them and as a pharmacy student, I say that pharmacy has no UNIFIED lobby SHAME ON US. Pharmacy is fragmented between many groups, hospital, community, independant, managed care, extended care. if these groups had were to work together, we would be easily as strong lobby. but many pharmacists don't participate in any group. many groups work against each other. NP's and PA's are in many cases the only prescribing athority in an area, especially rural areas, it would be rediculous say that they should not prescribe, and as for mistakes by "ancillary" prescribers, I don't think that any pharmacist could honestly tell you that they see more errors from them than from "real" MD's I process incorrect RX's all the time from doctors... a pharmacist is a specialist in drugs just as a cardiologist is a specialist in the heart, and I agree that we should have prescriptive athority but patient care should be colaboration between fields, not sniping over who should or shouldn't be doing something. > a pharmacist is a specialist in drugs just as a cardiologist is a specialist in the heart, and I agree that we should have prescriptive > athority but patient care should be colaboration between fields, not sniping over who should or shouldn't be doing something. A Pharmacist is a general authority on a wide range of drugs. I certainly hope a cardiologists knows more about certain cardiac drugs than I do as a Pharmacist as he has observed their action first hand in a variety of patients. What is really important, does the person taking care of a person's health really know what he or she is doing. Being a doctor, pharmacist, nurse, NP, PA, etc., is no absolute immunity from doing stupid things. Hawki63 wrote >in the US more than 65% >of primary care medicine >is given by NP and PAs... This statement does not jibe with my experiences as a patient and a pharmacist. I would say the number is closer to 15%. IMHO. YMMV. Without any disrespect to NPs and PAs. Perhaps your experiences are not of the norm There are currently more than 170,000 nurse practitoners licensed in the US..."the majority working in primary care" dems the stats course they ARE more likely to be seen in managed care,,than private... could be why you are "missing out"... > Hawki63 wrote > [quoted text clipped - 7 lines] > YMMV. > Without any disrespect to NPs and PAs. |
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