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Professor of Clinical Pharmacy and Family Medicine Robert C Byrd Health Sciences Center Schools of Pharmacy & Medicine West Virginia University PO Box 9520, Room 1124 E Morgantown, West Virginia 26506-9520 fax 304/293-7672 cdponte{at}hsc.wvu.edu
Published Online, July 18, 2006. www.theannals.com, DOI 10.1345/aph.1H334b
In a June 23, 2005, press release,2 John A Gans PharmD, executive vice president and chief operating officer of the American Pharmacists Association, reiterated the association's position that "patients should receive their medications without harassment and interference." However, the association also maintains that pharmacists have the right to refuse to fill a prescription based on moral and ethical grounds. Importantly, patient care must not be compromised as a result of such action, and drug delivery systems must be in place to guarantee that patient abandonment (real or perceived) is never realized. It is important to note that physicians and nurses have been operating under conscience clauses in their respective practice acts for many years, thus allowing them to withdraw from participation in professional activities deemed to be morally or ethically objectionable.3-5 The American Medical Association's House of Delegates recently adopted 9 "Principles of Medical Ethics" to guide physician conduct and behavior.6 The following principle attests to a physician's freedom of choice: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care." Although this principle is not legally binding, it appears to legitimize a physician's decision to refuse treatment deemed personally unacceptable.
Wall and Brown use the above mentioned factual example and a hypothetical case to question the right of pharmacists to refuse to fill prescriptions based on personal and ethical grounds. Upon closer scrutiny, the article appears more like a lesson in medical terminology, reproductive physiology, and emergency contraception. Particularly troubling is their portrayal of pharmacists as nothing more than unethical technicians, inept communicators or, at best, "incomplete" quasiprofessionals who put political agendas before patient care. The misguided notions that the patient represents a pharmacist's customer, with no expectation of a professional encounter, and that the pharmacist should merely carry out a physician's orders, without independent thought, judgment, or action, reinforces my opinion that the authors are woefully misinformed about contemporary pharmacy practice. I am convinced that Wall and Brown are unaware of the paradigm shift to the pharmaceutical care model that occurred 15 years ago, the implementation of collaborative practice initiatives between pharmacists and physicians, the growth of consultant and senior care pharmacy practice, and the opportunities afforded pharmacists under the new Medicare Part D guidelines for providing expanded patient care services.7 Wall and Brown would be well advised to examine 2 recent publications that provide a perspective on contemporary pharmacy education and postgraduate training programs that prepare pharmacists to provide a sophisticated level of pharmacotherapy for selected patient populations.8,9
The authors' sweeping generalizations and assumptions about the professional conduct of pharmacists are grossly unfair, represent conjecture at best, and attest to their inattention to adequately researching the subject matter prior to sharing their opinions with the medical community at large. In fact, all one has to do is review the authors' reference list to see that they did not do their "homework." There is only one reference (of 14) that mentions the pharmacy profession (eg, in reference to incomplete professionalization) and it is nearly 40 years old!10
Despite their myopic view of the profession, Wall and Brown confront the reader with unavoidable realities regarding shortcomings that the profession still faces. The following quote from the article is particularly thought provoking and rings true today: pharmacists "do not exercise full autonomous control and authority over their area of expertise." We have struggled for many decades to shed that perception of ourselves as being just glorified technicians—those who merely "lick and stick" and "count and pour." Historically, we have succeeded at intraprofessional communication (pharmacist to pharmacist, organization to organization), but we still struggle with articulating our role and value to other healthcare providers, third party payers, and most importantly, the public. For example, the Public Policy Institute of California conducted a statewide survey in 2005 to assess public opinion of the state's population.11 Germane to this discussion, only 18% of respondents knew that emergency contraception was available from a pharmacist without a prescription. Whereas the reason(s) for this lack of awareness are unknown, one must wonder whether the blame lies, in part, with the pharmacy profession itself.
Nonetheless, during the past 10 years, the expanding roles of the pharmacist in medication management and collaborative practice, as well as the beneficial clinical, economic, and humanistic outcomes ascribed to these services, have been articulated in the literature.12,13 These well known success stories have validated the role of the pharmacist as the rightful provider of pharmacotherapy and have provided the fabric with which to cloak the pharmacist with the mantle of complete professional.
The authors are correct in implying that pharmacists neither fully function as professionals nor make appropriate decisions when critical elements of the medical record are inaccessible to them. This only reinforces the need to collaborate with physicians, other healthcare providers, and informatics experts in developing an infrastructure that would facilitate access to a shared electronic medical record. The electronic medical record can serve as a link among interdisciplinary providers and the patient to facilitate care coordination, eliminate redundancy, streamline care, and optimize clinical, socioeconomic, and humanistic outcomes.14 Simply persuading physicians to consistently write the diagnosis on a prescription would go a long way toward solving this problem. It is certainly true that we have come a long way, but, as we have seen from this article and the perceptions of its authors, we still have a long way to go.
References
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