How M.D.s and R.Ph.s can work better together

May 2, 2005

As pharmacy expands its scope of practice, it will inevitably be forced to interface with other professions in new ways. At every point, it is important to clearly define the nature of the pharmacy profession, its relationship to other professions, and its position in the greater institution of health care.

As pharmacy expands its scope of practice, it will inevitably be forced to interface with other professions in new ways. At every point, it is important to clearly define the nature of the pharmacy profession, its relationship to other professions, and its position in the greater institution of health care.

I've practiced pharmacy for three years in a county hospital, and, during that time, I attended medical school and rotated through a 1,000-bed tertiary care university hospital, as well as the hospital where I'm employed. I'd like to share my insight into the physician-pharmacist relationship and the expansion of pharmacists' scope of practice. I'd also like to share my thoughts on the ways in which pharmacy could become more active in patient care and, thereby, not only improve outcomes but advance the profession as well.

When it comes to ideas of what a pharmacist is and does, there are as many as there are physicians. One extreme is the antiquated notion that R.Ph.s are automatons whose sole responsibility is to dispense precisely what the physician prescribes. The other end of the spectrum is the expectation that R.Ph.s are walking pharmacopoeias and complete drug and therapeutics experts. These extremes are the exception, not the rule; the attitude of most physicians falls somewhere in between.

In many states, pharmacists can collaborate with physicians as practitioners in clinics, and there are data showing that R.Ph.s can be very successful in such settings. Likewise, pharmacist participation in hospital rounds has become commonplace. One barrier to the further expansion of pharmacists' scope of practice is the wide variability in knowledge, training, skills, and motivation among pharmacists. This variability makes it difficult to gauge the quality of pharmacy input and, in my experience, has worked to damage the overall reputation of pharmacists among other healthcare providers.

Often pharmacists review physician orders at a distant location. Although suggestions can be made by contacting the physician, this is an awkward and inefficient system. Further, the ability to make suggestions is limited by separation from the clinical circumstances of the patient. When clinical R.Ph.s are members of the team, suggestions can be made in real time. In my experience, pharmacists are often able to help teams develop treatment plans that are more cost-effective, convenient to implement, and in line with formulary concerns of the institution. Also, R.Ph.s are able to scan the patient's medication list for duplications, drug-drug, or drug-disease interactions; monitor for side effects and efficacy; and provide pharmacokinetic services.

Providing pharmaceutical care requires R.Ph.s to have a basic set of facts regarding specific drugs and the clinical reasoning to apply those to individual patients. With the advent of rapidly accessible drug databases, there is less emphasis on the acquisition of factual knowledge during pharmacy training. I see this as a subtle disconnect between pharmacy training and the expectations and realities of the work environment. Although it is impossible for anyone to learn all facts about all drugs, it is not unreasonable to expect R.Ph.s to be intimately familiar with many drugs and have the clinical skills to use them appropriately. Pharmacists' contribution to the team should include drug knowledge, not simply producing their PDA faster than the physician.

The scope of pharmacy practice has expanded considerably in the past few decades. Likewise, the way pharmacy is viewed by other healthcare professionals continues to evolve. By addressing the needs and expectations of the healthcare team, R.Ph.s can improve patient outcomes and gain the respect and professional satisfaction that comes with increased clinical responsibility. Although my experience has been limited to hospital and clinic settings, I believe these ideas could be extended to community pharmacy practice.

THE AUTHOR, a practicing pharmacist, is now completing his third year of medical school at the University of Alabama at Birmingham.