SMA op-ed: Patients should be wary of simple solutions
April 11, 2018
The Pharmacy Association of Saskatchewan has rented billboards to advertise pharmacists’ ability to prescribe birth control pills and drugs for ailments such as bladder infections. The selling point is simple enough: these are everyday needs, and you don’t have to be a highly-trained doctor to meet them. Patients would get fast and convenient service, and the risks of anything going wrong are low. So what’s the problem?
We at the Saskatchewan Medical Association are all for improved patient access to high-quality care. Doctors don’t lack for things to do and we are happy to share duties with other professional colleagues so that everyone is working safely to the full scope of their training. Our collective duty is to our patients, whose interests must trump ours. Unfortunately, sometimes problems that appear to be simple and easy to fix turn out to be signals of something more complex.
And that is precisely why we have raised concerns about this new development. The SMA believes that it is critical for patients to have what is called a medical home: a continuous source of comprehensive care, where patients have a relationship with their family physician and other providers. In such a setting, signs and symptoms of a health issue can be diagnosed and interpreted in the context of a patient’s overall life and health experience. And appointments for birth control, for example, are opportunities to discuss healthy sexual practices and other preventative measures. This isn’t pop psychology or overkill – it is verified by a great deal of research. Put simply, fragmented care increases the risks of something going wrong.
Good health care is a team activity based on collaboration, interdependency, communication, and trust. Our patients expect this of us and often think it is happening far more than it is. Many community pharmacists practice in independent facilities and may have little or no relationship with their patients’ doctors, and at best a partial understanding of the patient’s overall health. Will the pharmacist accept responsibility for an adverse event? Will the diagnosis and treatment automatically become part of the patient’s health record? Will the patient get conflicting advice from her doctor and her pharmacist, and if so, what is she to do?
Pharmacists have also announced their hope for a greater role in managing hypertension, suggesting that they can save the system $423 million over three decades. Presumably, the majority of these savings would be due to fewer physician visits. Given that pharmacists are allowed to bill patients directly for their visits, at least some of that $423 million will come directly from patients’ pockets. There is also ample research showing fragmented care is ultimately more costly.
Nor can we overlook conflict of interest. Community pharmacies are businesses that make more money when more drugs are dispensed. Certain medications allow pharmacies to make better profits. This is why it has been beneficial for the prescribers and dispensers to be separate parties. We’re not suggesting that pharmacists want independent authority to prescribe in order to line their pockets; but in a society where over-prescribing is a common problem, the last thing we need is a further incentive to medicate.
From time to time there will be honorable differences of opinion about who should do what in our increasingly diverse and specialized health-care system. We believe these disagreements can and must be settled by a process that transparently seeks solutions in the public interest. No profession, including ours, can claim a monopoly of wisdom about what best serves the public. This is a system with many moving parts, and their movements must be harmonized to get the best results. Just as health care is more effective in teams, so, too is decision-making about professional roles.
Hence we suggest that before any further decisions are made, all of us – professions, regulators, government, health care leaders, and members of the public – should sit down and develop a principle-based process to guide discussions about scope of practice. We need to consider best practices, competencies, risks, benefits, and alignment with broad system goals. Any solution should bring professions closer together, not further isolate them from each other.
Dr. Joanne Sivertson
Saskatchewan Medical Association