Pharmacists and Pharmacies: Mental Models

February 2, 2014

This is the final entry in a 4-part series examining the current policies and regulations that pose a barrier to pharmacy practice change. The recurring argument has been that for pharmacy practice to move forward, the historical coupling of the pharmacy-pharmacist relationship must be undone.

Part 4: The Mental Model

In Part 1, I demonstrated that a pharmacist’s patient care services need not be in a dispensary. Medication reviews, therapeutic checks, injections, and even medication counselling can occur in any setting. In Part 2, I noted that pharmacists needed to see value in their services directly, and recognize that compensation indirectly through dispensing fees and product sales cripples the expansion of patient-centred care. In Part 3, I highlighted the increasing conflicts of interests that advocacy associations face in trying to represent the interests of both pharmacists and pharmacies, and that the associations must choose one side or the other if either side is to be adequately represented.

In a 2010 CPJ article titled “Are pharmacists the ultimate barrier to pharmacy practice change?”, Meagan Rosenthal et al. attempted to describe a “pharmacy culture”, suggesting that intrinsic pharmacist characteristics were likely the reason for a slow adoption for expanded pharmacy practice change. In this series, I’ve challenged that idea by demonstrating that the operating model for pharmacy practice is the problem. This operating model of pharmacy practice informs regulatory policies, attitudes of government officials, journalists, physicians, and yes — even pharmacists themselves. It defines the pharmacy practice paradigm as one where pharmacists and pharmacies are connected in an interdependent manner. The failure of the entire pharmacy community — from academics and hospitalists to the advocacy associations and regulatory bodies — to understand the two parties as separate entities with diverging visions of the way forward for pharmacy practice is likely the most significant barrier to pharmacy practice change.

So what does pharmacy practice untethered to a dispensary look like? Perhaps it involves pharmacists performing medication reviews in physician’s offices at the same time patients get their annual checkup. It’s one visit for the patient, and provides an opportunity for physician and pharmacist to work collaboratively and share administrative costs. Perhaps it means pharmacists partnering with dentists to provide smoking cessation programs directly in their offices. It works as a marketing tool for those dentists, and patients understand the link between smoking cessation and oral health. Perhaps pharmacists could help reduce wait times at urgent care clinics by attending to minor ailments and screening for viral infections. This would shorten wait times and lead to better care overall. These are all activities pharmacists currently do inside pharmacies, but there is no reason for pharmacists not to be able to share office time with other health practitioners and get paid for those services directly.

I recognize the idealism in this paradigm, but ideals are what we should be working towards. The future need not seem so far out of reach. Many of the activities mentioned are already going on in select settings. If pharmacists are given the opportunity to practice outside the box — big box stores, that is — then perhaps progress can be accelerated. Once pharmacists demonstrate the ability and willingness to exercise their limited expanded scope, other initiatives such as a pharmacist-led hypothyroid management programs, anticoagulation clinics, pharmacist-led travel vaccine clinics, or general pharmacy practice clinics become more than just pilot projects or niche practices and can gain traction to be spread through the country and taken up by patients.

And what about further into the future? There is a desperate need to fix the way prescribers get their drug information in practice. Currently, physicians obtain the majority of their drug information through industry reps, where the information is likely to be skewed in favour of newer, more expensive products with longer patents and lesser known safety profiles. A pharmacist-focused advocacy group might be able to put forth a proposal that demonstrates the potential cost savings of having pharmacists be the sole providers of drug information to prescribers.

And what about the role of pharmacists in public advocacy for patients in the media, which some have argued is an ethical obligation for any health profession? Where was the voice of pharmacists speaking against CETA patent provisions which would extend patent terms and delay generic drug entry, making medications more expensive for lower-middle class patients who typically do not qualify for welfare but do not have an employer-sponsored drug plan? What about the collapse of CAMR legislation in late 2012 by the Harper government which would have improved access to medicine for developing countries? What’s the pharmacist role in national pharmacare program? Do pharmacists have input on the new OTC labelling guidelines to ensure patients better understand self-care products? Drugs are our realm, and we have been notably absent from many of these public conversations.

And what about patient health initiatives that are directly at odds with the pharmacy operators? Could a properly focused pharmacist-advocacy group call for halting the sale of a variety of products in pharmacies that conflict with pharmacy practice, such as: a) junk food; ) antibiotic cleansers which contribute to antibiotic resistance; c) homeopathic products which have no therapeutic benefit and may even be downright dangerous to patient health; and d) the 200 size of “Tylenol 1’s — the caplets; and 100 generic Gravol”.

It may not all pan out exactly as envisioned, but it must be clear by now that simply hoping the turbulence settles down into the status quo is not an option. I am not a call to action type of guy. Pharmacists must be collectively convinced that this is how they want to proceed. This series was an attempt to unify the ideas and provide some perspective on just why and how pharmacists and pharmacies should no longer operate in tandem. As pharmacies rush to enter advertising deals with generic drug manufacturers to skirt the ban on rebates, pharmacists ought to be rushing the other way. And the only way to do that is to recognize that the future of the profession lies outside of the dispensary.