A patient comes to the pharmacy.
“I cannot reach my family doctor,” says the patient.
“Let me see if I can help you,” the kind pharmacist replies.
“I think I have a urinary tract infection (UTI). I usually get the antibiotic Nitrofurantoin twice a day for 10 days,” says the patient. “It feels like a UTI, and that medication has worked for me in the past.”
“OK. Here you go,” says the well-meaning pharmacist as she provides the requested antibiotic and advises the patient how to take it properly. The patient is happy and avoids the busy emergency room – a win-win scenario for the overburdened health-care system and the patient. The patient is spared a trip to the busy ER, urgent care clinic or family doctor’s office (if the patient has a family doctor at all) and the busy family doctor has time to see other patients with other problems. A simple problem with a straight-forward remedy and no harm possible, right?
This outcome is typical in eight provinces, with Ontario planning to follow suit on Jan. 1. The intent is straightforward: lessening the patient burden on physicians, allowing them to focus on more critical care; helping to alleviate financial pressures on the health-care system; timely access to medications without long lineups or delays for patients.
Pharmacists are smart. They know about medications. They go to university and get a degree. They write national board examinations. They are health-care professionals and important members of functional health-care teams. Pharmacists assist physicians and patients with safe medication dosing; they monitor for medication interactions; and they provide counselling about possible side effects. Pharmacists support their patients with guidance. They support their community by running businesses and dispensing medications. They support doctors by helping with drug shortages, checking on dosing based on weight or kidney function, and ensuring medications are taken correctly. Pharmacists’ knowledge of medications is invaluable.
Pharmacists’ knowledge of medications is invaluable. But are they diagnosticians?
But are they diagnosticians? While the practice has become common, it does have some detractors. In 2019, the Royal Australian College of General Practitioners dismissed the idea, saying it is “inappropriate and unsustainable.”
So, let’s change the scenario a little.
A patient comes to a family doctor and the process is longer and more complicated.
“I have a UTI and I typically take the antibiotic Nitrofurantoin twice a day for 10 days,” says the patient.
“OK,” says the family doctor, “What are your symptoms; is there any blood in the urine; is there any change in urine flow; is it worse at different times of the day; how long have you had this; any fevers; any skin lesions; any new sexual activity, when was the last time you had this and how was it treated?” And so on, until the family doctor is satisfied that a UTI is the most likely diagnosis and other serious problems are satisfactorily ruled out.
A physical exam follows: vital signs including blood pressure, heart rate and temperature; examination of the chest, heart, abdomen, skin, lymph nodes and other body systems (if appropriate).
Then there may be a need for urinalysis and urine culture, blood work, X-rays, ultrasounds or still others. Sorting through which tests are needed and where follow-up is required takes training and experience in history taking, physical examination and differential diagnosis. Often, there is more to the process than prescribing a medication.
“Is this a kidney infection?” ponders the family physician “Kidney stones? Vulvar cancer? Chlamydia? Bladder cancer? What harms may come from inappropriate antibiotics? What follow up is needed? What am I missing?”
But why is the diagnosis of a urine infection not just a transactional relationship, as in the first scenario? Why is it sometimes more than simply “this is what I have, and this is what I need?” It is because there are dozens of diagnoses in the case of a probable UTI in which antibiotics will not solve the issue or should not be used. In fact, antibiotics can make some things worse and could hide serious conditions.
Minor ailments are easy to treat at the pharmacy once they are diagnosed – but which ones are those? Dysmenorrhea (painful menstrual periods), cold sores, musculoskeletal strains and conjunctivitis (pink eye) seem like easy ones but consider this: What if the patient with dysmenorrhea really has an ectopic pregnancy; the patient with cold sores has a basal cell carcinoma; the patient with a muscle strain has polymyalgia rheumatica; the patient with pink eye has acute angle closure glaucoma. Those are quite a bit different, certainly not minor, and potentially serious, life threatening or sight-threatening conditions, especially if mistreated.
As family doctors, we have a duty to document all patient interactions and store these records for at least 10 years. We need to take a history, perform a physical exam in a professional manner in a private room, consider a differential diagnosis, order appropriate investigations, develop a treatment plan and organize follow up. We must carry medical malpractice insurance. We must continue our medical education annually to maintain the current standard of care.
We greatly appreciate pharmacists contributing to care with COVID-19 vaccinations, annual influenza vaccinations and medicine reconciliation as well as providing continuation of prescription medications for stable, chronic conditions. We wonder, however, what the unintended consequences of the diagnosis and treatment of “minor” conditions in this way will be.