Opinion

Dr. Pharmacist?

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.

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14 Comments
  • ACG says:

    As a pharmacist, I can say that we do ask all the above differential questions when inquiring about uti self diagnosis. We must challenge with subjective and objective information in order to challenge the self diagnosis. We also follow up with patient to assess effectiveness and safety of chosen treatment if there is a need to treat

    We also refer to physician when appropriate, we must also keep all referral, assessments and follow up documentation for 10 years. We do this for basically Pennies compared to doctors ( debate for another day).

    I really don’t understand why there is push back on this . As a PharmD, I have the clinical expertise to triage patients. Previously , we were doing all of this without the proper tools.

    Now we are equipped to actually make a difference.

  • Jen says:

    A parent’s perspective….
    I recently utilized the prescribing pharmacist option in AB, and I am so thankful it was available to me. My 9yr old daughter had barely gotten over the flu when she became sick with a fever and sore throat (along with some cold symptoms). She could barely sip water. Three days into it, at 6pm on a snowy Sunday night, I noticed she’d broken out in a head-to-ankle sandpaper like rash all over her body. I brought her to the local pharmacy where they did a rapid strep test and announced it as “fully positive”. Antibiotics were prescribed and taken that night. The next morning, my daughter woke-up and immediately said, “my throat feels better mommy.”

    My FP was able to see us three days later. I was shocked when she proceeded to tell me that my daughter might not have needed antibiotics because many kids naturally have strep bacteria in their throats. She proceeded to lecture me on the neg consequences of kids taking antibiotics, making me question and feel bad about my decision to treat my daughter. As this was very out of character for my usually wonderful FP, I can only guess that she was annoyed that we’d been diagnosed and treated by a pharmacist.

    What was the alternative for us? What condition would my daughter have been in if we’d waited 3 days to see my FP? Should we have gone to the already overburdened urgent care and had a sick child wait long into the night to get a strep test done?

    The prescribing pharmacist was the ideal option for us in that moment. I feel thankful to have a wonderful FP, when so many don’t. But there is also room in the system for pharmacists to play more of a role supporting patients.

  • Dr. Rob Murray says:

    Pharmacists should track their patients and give them a call in 1 or 2 years to see if they have experienced worsening health problems. Infection rates of ticks vary from year to year and by location but are generally in the 25%-33% range so not every tick bite would be expected to cause Lyme disease. Ticks feed on rodents and can transmit many more serious diseases such as Powassan virus, Babesia, Anaplasmosis etc. The minimum attachment time in humans has never been established. There is evidence that nymphs may be able to transmit in as little as 18 hours. The risk is never zero.

  • Dr. Rob Murray says:

    Undertreatment of Lyme disease is a growing problem in Canada where PHAC has prioritized the preservation of the antibiotic supply over returning Canadians to health. Pharmacists can now access and treat tick bites in Ontario, Nova Scotia and Montreal with a single dose of doxycycline. The only thing one pill has been shown to do is to prevent the rash, not the disease. There is evidence that this protocol push Borrelia bacteria into an antibiotic tolerant neuroinvasive persister state leading eventually to Alzheimer’s. Borrelia are slow growing, slow replicating organism and initial treatment should be 21-29 days of doxy with a repeat if necessary.

    The single study was underpowered, never replicated and patients weren’t followed to see if anyone actually got sick. Lyme is a multi-staged, multisystemic, life-altering, life changing disease, the infectious disease equivalent of cancer. Infectious disease doctors have focused their attention on the acute symptom of the disease, namely the EM rash which occurs in less than half of patients. All pandemics from polio on down have chronic sequelae and the hidden, ignored pandemic of Lyme disease is no exception. When the rash disappears and the patient is still ill then 95% medical practitioners believe dogma promoted by the CDC/ IDSA/ AMMI [Canada] and believed by 90%-95% of medical practitioners that: Lyme disease is difficult to acquire, easy to diagnose, readily cured with a short course of antibiotics. If a patient has symptoms following treatment either initial diagnosis was wrong or they have Post Treatment Lyme Disease Syndrome [PTLDS] since there is no such thing as chronic Lyme disease.

    We are all for the reduction of the unnecessary use of antibiotics, but it is the appropriate use that is important. Cases of acne and prostate cancer are routinely treated for a year with doxycycline which blows that argument out of the water.

    We prefer the guidelines promoted by the International Lyme and Associated Diseases Society [ILADS] which defer to physician judgement and patient preferences. Canadian health care providers can also use the CEP tool https://cep.health/media/uploaded/CEP_EarlyLymeDisease_Provider_2020.pdf
    that allows for a repeat of a 10 day prescription of Doxycycline if needed. The science simply doesn’t justify the use of one pill.

    All health care providers should take the free CME approved online course, Managing Ixodes scapularis bites by Dr. EL Maloney at https://learn.invisible.international/ or https://www.lymecme.info/

    Reference: Controversies in Persistent [Chronic] Lyme Disease, Maloney EL, J Infus Nurs 39[6] 369-375; 2016-Nov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102277/

  • Susan says:

    I am not a pharmacist nor do I have any affiliation with any pharmacists. This article is highly insulting and I think probably politically motivated, in the turf protection sense. The antibiotic example was interesting, given that 30-50% of antibiotics prescribed in outpatient settings are inappropriate: about 25% are for UTIs. Those are prescribed mostly by family physicians. I recall the same criticism from physicians when nurse practitioners came into existence in Ontario. In my experience, they have been a great addition to health care delivery.

    • Jdv says:

      You are so right Susan. No pharmacist would give a repeat antibiotic dose without asking a single question about the repeat symptoms. Even they know what other diseases may appear as UTI in the patient. They will call for a medical consultation if there is any doubt in the situation.

  • Anthony says:

    Cruel twist of fate…..

    We’re now “providers” and other health care professionals are now doctors….

  • Leo P says:

    Drs. Abdulla and Schurter are on point. There are many other professions that want to become “Doctors without the training” – chiro, optometrists, naturopaths and dear god, homeopaths (do we still allow them to “practice”?). However, I believe the greatest threat to patients’ health may actually be the conflict of interest that pharmacists are being pushed into. According to a CPSO investigator, studies have shown that when an arms-length relationship does not exist, more interventions (more tests, more Rx etc,) follow. For example, patients of a physician whose husband/wife runs the pharmacy next door will receive more prescriptions than necessary. When radiologists were allowed to add additional procedures without the approval of an MD, more irrelevant tests were being done. More tests are ordered by cardiologists if their office performs the tests. The pharmacy business is all about profits but they want us to believe they are above the temptations of conflict of interest.

    Recently, Shoppers Drug Mart, which is trying to turn pharmacists into physicians, donated $ 3 million to get U of T Public Health and U of T School of pharmacy to conduct “research”. This is a weakly veiled attempt to wash self-serving “research” to make pharmacists look more like physicians.

    I wonder what this industry would say if doctors demanded that they be allowed to sell medicines to their patients, thereby bypassing the pharmacist?

    • Istvan Szarka says:

      Well put Leo P

    • AC says:

      Where I live, many doctors (family and specialists) hand out month-long supplies to patients via vendor samples. I would not be opposed to doctors dispensing medicines, which is already included within their legally defined scope of practice. Pharmacist prescribing as proposed by the Ontario legislation is not anything truly different than what is currently done in practice. If you look at the drug classes involved in each of the 13 ailments, there are therapeutically equivalent dosages often within the same medication class already available without the prescription. This scope expansion essentially further regulates and codifies what has been done in the past, while allowing access and authority to reduce direct patient costs, as pharmacists can now prescribe medications that can be directly billed to public/private insurance

  • Ana says:

    The pharmacists’ job is to check doctors’ prescriptions for errors. To do that, we must know much more than you suggest. We already take history and assess every patient. Then we adapt the prescriptions to what’s appropriate and send letters to the prescriber about it.

  • Jeff Taylor pharmacist/educator says:

    Hi Drs Abdulla and Schurter,

    This is such a good issue to debate in health care, and it deserves the input/concerns you provided, so thanks!

    I teach ‘minor ailments’ at the Univ of Sask to pharmacy students, and have followed the launch of the prescribing program in that province. The developers were very careful to ensure encounters that occur as — “Ok, here you go” — do not happen. Every province has extensive guidelines on when to prescribe for something like a UTI, how the process must unfold, and also when NOT to go down this path. Assessing Red Flags (listed out) will be critical, as is an assessment of other possible explanations for the symptoms. IF any doubt, medical referral must be the recommendation. In our own program, we spend a lot of hours (in class and in practice labs) going over a wide range of topics like cold sores, skin conditions, contraception, and headaches, all ones relevant to prescribing. The training we provide is not perfect, but pharmacists take this role seriously, and do our utmost to make sure the recommendations we make have patient safety at the top of the list. Lastly, for a bit of perspective, in looking at the program (again in Sask), I believe pharmacists all across the province prescribed about 18,000 times in a recent year. My best guess is that those same pharmacists likely dealt with about 250,000 minor ailment situations over the same time period, ones that did not involve prescribing — helping with coughs, itchy rashes, sore backs, teething pain, constipation etc.

  • Michael Nashat says:

    The Article First States “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.”

    EIGHT PROVINCES. Ontario is one two provinces that doesn’t allow this. Why would we believe that Ontario Pharmacists are not be able to provide the same level of “SAFE” care as pharmacists have been doing in other provinces/states. There has been no evidence of the stated unintended consequences in Other provinces/or states where pharmacists prescribing is the norm and not a new endeavor.

    It will be an exciting time for pharmacy and great win for the health care system as we expand our capacity and allow physicians to focus on more complex cases that is aligned with their education and training.

  • Randy Luckham PharmD says:

    This may be a helpful read https://www.ocpinfo.com/wp-content/uploads/2020/12/Minor-Ailments-Advisory-Group-MAAG-Summary-of-Recommendations-Pharmacist-Prescribing.pdf particularly how minor ailments were defined for the purposes of this initiative and which ailments were chosen in order to specifically decrease pressure on urgent care. Assessment (not diagnosis) then referral or treatment advice – what pharmacists do every day, really. Hopefully this program will augment the tools pharmacists have at their disposal to further help patients and alleviate pressure on the system.

Authors

Alykhan Abdulla

Contributor

Alykhan Abdulla is a comprehensive family doctor working in Manotick, Ontario, member of the Ontario Medical Foundation Board, Bruyere Foundation Board, College of Family Physicians of Canada and Director for Longitudinal Leadership Curriculum at the University of Ottawa Undergraduate Medical Education. 

Matthew Schurter

Contributor

Matthew Schurter is a comprehensive family doctor in Sunderland, Ontario and a Family-Practice Anesthesiologist in Port Perry, Ontario. 

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