It’s late in the evening and you just got home. You’re preparing dinner and you start experiencing the dreaded but familiar signs of a urinary tract infection (UTI). Throughout the night, you keep running to the bathroom, uncomfortably passing cloudy urine. With the doctor’s office closed and no nearby walk-in clinics available, you realize that your only option for a prescription you’ve taken countless times before is the emergency department (ED).
Anxious and in discomfort, you wait for hours in the busy ED, knowing that you’re occupying a spot someone with a more acute condition may need. This situation adds to the ongoing “hallway medicine” problem in Ontario, highlighting the urgent need for accessible and efficient health-care solutions to address common ailments like UTIs.
If you’re one of the lucky ones, you would have access to a primary care doctor or nurse practitioner. But the latest research from the Ontario College of Family Physicians suggests that 2.2 million Ontarians are without access to a family doctor.
Between choosing emergency care or no care for minor ailments, another option exists for patients in Ontario – since January, you can be seen by a pharmacist; upon an assessment through a standardized algorithm, you will receive an appropriate prescription.
Minor ailments refer to short-term conditions that can often be self-diagnosed and managed without major interventions. These are conditions that do not require lab tests to initially identify the condition and require minimal follow up. Both Ontario and British Columbia joined other provinces in leveraging pharmacists as prescribers in 2023.
In a time where patients experience shortages of health-care professionals and long wait times, this can make a big difference, especially if the next best option is no health care at all.
Pharmacist prescribing is not new.
Not everyone is on board with these expansions in scope. There is worry that pharmacists are unprepared or that this new system will bring challenges to patient safety. However, pharmacist prescribing is not new. In the United Kingdom, patients have received care from pharmacist prescribers since 2003. In Alberta, pharmacists have been prescribing since 2006 and can also order lab tests.
Pharmacists have expert knowledge on medications. Graduates of Ontario pharmacy schools receive a professional doctorate degree, three years of training and a full year of hands-on clinical practicums within both community and hospital settings. Pharmacists are ready.
Pharmacists have already treated almost a quarter of a million patients since Ontario’s expansion in scope, demonstrating the demand and need for this type of care in the community. However, as patients leverage this to scale, we need to continue to study and evaluate the benefits and drawbacks of the program.
To maximize such benefits, pharmacist prescribing must be conducted with a collaborative approach. With each prescription, the primary care physician must be informed. Collectively, this ensures that patients are safe, that follow up will be provided and, ultimately, that patients get the care they need on a timely basis.
From a community perspective, physicians will face reduced workload in areas that pharmacists can take on. That way, they have more capacity to address complex conditions. As a result, pharmacist prescribing provides a win-win outcome for patients, health-care professionals and the health-care system as a whole.
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“…we need to continue to study and evaluate the benefits and drawbacks of the program.”
“However, pharmacist prescribing is not new. In the United Kingdom, patients have received care from pharmacist prescribers since 2003. In Alberta, pharmacists have been prescribing since 2006”
So…hmmm…one wonders what sort of research has been done on pharmacist prescribing in the UK and Alberta. Because right now, in Ontario, the measures of ‘success’ being crowed about by the OPA and government are number of pharmacist services utilized and number of prescriptions issues by pharmacists. I am pretty sure that these two variables would not survive the ‘acid test’ of success metrics. While they’re at it, why don’t they measure “patient satisfaction” which has been repeatedly shown in research to be inversely proportional to favourable outcomes and quality of care.
I completely agree that there are gaps in the Canadian health care system that need to be filled to provide better care to patients. However this is not a win-win scenario for everyone involved. May be physician’s workload will reduce but community pharmacists have been asked to take on a lot more on a background of an already busy pharmacy workflow. And all of this while they do not see any pay increase, the additional revenue that comes in is pocketed by pharmacy owners. This solution does not take into account the needs of the pharmacists directly providing the service and does not compensate them properly which is a shame because this is exactly how people get burned out.
As a community pharmacist myself, I genuinely understand and empathize with the pressures that frontline pharmacists are currently facing.
Your reflections on the changing landscape of the Canadian healthcare system highlight both the challenges and opportunities that lie ahead for pharmacists. It’s undeniable that frontline pharmacists are under significant pressure, especially when taking on expanded responsibilities without a commensurate increase in compensation. This can indeed be a recipe for burnout and feelings of being undervalued. Yet, this moment of evolution also offers a chance for pharmacists to assert their role as key clinicians in the healthcare chain. By combining professional negotiations with a firm stand on ethical responsibilities, pharmacists have the opportunity to advocate both for patients’ best interests and their own rightful recognition and remuneration.
As roles evolve, so should the understanding and support systems that ensure those on the frontline aren’t left overwhelmed or undervalued. The healthcare system’s success relies on the well-being and fair treatment of its dedicated professionals, and pharmacists are undeniably at the heart of that equation.
We are all in favour of reducing barriers to care provided the treatment provided by pharmacists is based on the best available science. Allowing pharmacists to diagnose and treat tick bites in Nova Scotia with a single antibiotic dose of an antibiotic [described as a homeopathic dose by Dr. Christian Perronne] will not stave off Lyme disease and is likely to backfire on patients. It might work if you believe that the rash is the disease. The 2019 Quebec INESS Report produced by a balanced panel of experts concluded that there was insufficient evidence to support this procedure by pharmacists.
It’s all based on a single small study of 235 patients was never replicated and patients weren’t followed to see if anyone actually became ill. The original basis of this was the 2001 Nadelman study that showed that a single dose of doxycycline stopped Lyme disease not in 87% of mice, but rather, in 20 to 30 percent at most.
Lyme was discovered by a rheumatologist [Dr. Allen Steere] in the mid 1970’s and rheumatologists prefer diseases with hard edges, objective signs that they can measure such as the much overemphasized rash that occurs in less than half of patients. The Infectious Diseases Society of America [IDSA] decided that the acute symptom [the EM rash] was the disease and once the rash was gone [end point] the patient was better. Lyme is a multi-staged, multi-system, life-altering, life threatening disease, the infectious disease equivalent of cancer.
There are no plans to do a follow-up study and have NS pharmacists phone their patients after a year to see if any are experiencing worsening health problems that could be due to complex disseminated Lyme. Patients don’t die and they still buy lots of medications to deal with their worsening symptoms. Medicine has lost its way and treats, not cures disease. The paradigm of modern medicine is to palliate with
prescriptions that provide life-time annuities to the companies.
A single dose only prevents the rash, not the disease. Dr. Monica Embers has access to a primate lab and believes that a single dose will drive Borrelia into an antibiotic tolerant persister form that is likely to become neuroinvasive and go on to cause neuroborreliosis and our most expensive disease, Alzheimer’s.
The downside for patients receiving a single dose is that they will fail to seroconvert and will receive a false negative test result if they later fall ill. Patients expect to be informed of both the negative and positive benefits of treatment. The flawed test used in Canada misses at least a third of patients who truly do have the disease but physicians haven’t been informed that both the Lyme guidelines and tests promoted here are flawed. The worst thing you can do for patients is give them a false-negative test result. Instead the Association of Medical Microbiologist and Infectious Diseases [[AMMI] Canada warn physicians of false positive test results.
AMMI have a death grip on this disease in Canada and refuse to talk to anyone wo won’t accept dogma promoted by the CDC/ IDSA/ AMMI [Canada], PHAC 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.
AMMI Canada doctors are only interested in patients that can pass their test and very narrow set of criteria. Once they have been treated for 10 days and are still suffering they are medically abandoned along with the family docs who have to live with their patients. Medicine is based on science except where it becomes inconvenient as in the case of Lyme.
Pharmacists and all healthcare professional should be encouraged to take the free online CME approved course given by Dr. E. l. Maloney, Managing Ixodes scapularis bites available from [IN]Visible International or http://www.lymecme.info. Canadian physicians and pharmacists can use the CEP Tool Early Lyme Disease Management in Primary Care which does allow for a second round of antibiotics in treating tick bites.
Lyme and tick-borne diseases [TBDs] are a growing ignored epidemic in Canada. There is consensus that the vast number of Lyme cases are under-detected in Canada but no agreement of what multiplier to use. You can safely multiply whatever number they give you by 10 and still be underestimating the extent of this hidden ignored epidemic. There is consensus that 10%-30% of patients will remain ill and are at risk of losing their employment, homes and lives. Antibiotics are still some of the best tools we have but PHAC has prioritized the preservation of the antibiotic supply over returning Canadians to health. It’s a travesty that many Canadians are forced to leave the country to seek treatment elsewhere, all this because the long-term disability insurance industry doesn’t want to underwrite the costs of treating long-Lyme or Lyme+.
The reason why we don’t have pharmacare in Canada is that the lobbyists don’t want it. The lobbyists that head PHAC are infectious disease doctors, they have the Minister’s ear are there to make sure that AMMI Canada maintains control of the agenda when it comes to Lyme disease management in Canada. Dr. Howard Njoo said that health is a provincial matter and provinces are free to do as they choose. Dr. Njoo will be the gatekeeper maintain control of the research agenda and the testing at the National Microbiological Laboratory.
Dr. Rob Murray [DDS ret.]
Lunenburg, NS
Board member Canadian Lyme Disease Foundation [www.CanLyme.org]
Pharmacy prescribing because of the shortage of family physicians and emergency care options is not an optimal solution. Pharmacists have expert knowledge on prescription and OTC medications. Frankly, I have used them often to discuss the optimal choice of a prescription medications or adverse effects. I was fortunate to have an in-house pharmacy team to discuss these concerns during my oncology practise. However, pharmacists are not experts in clinical assessment, even of minor ailments. And truthfully, they are not equipped to assess the severity of rashes, know psoriasis from eczema, or be able to discern whether a skin infection is amenable to oral antibiotics or requiring incision and drainage. They do not have training in clinical dermatology or necessarily have even have diagnosed patients with complicated UTIs (those with associated pyelonephritis i.e. kidney infections). Some have hospital experience and are more comfortable in this role.
My concerns include: 1) The risk of overprescribing of antibiotics –A very likely result when antibiotic resistant bacteria is already a serious concern.
2) Will privacy be afforded to individuals who are requesting a specific therapy – Will there be appropriate documentation of the problem for the family doctor?
3) Pharmacists may be able to address a significant number of issues appropriately. However people will undoubtedly come with more serious issues to avoid long ER waits. What will happen to those individuals?
4) Private interests (corporations) driving this healthcare change are motivated to boost their profits. The role of pharmacists should be developed by a consensus of multidisciplinary health care providers. Clinical training should be provided and a scope of prescribing practice developed.
The best way to address long waits in the ER and at urgent care clinics is to reduce the shortage among primary care practitioners. Improve access to Family Health Teams for new family medicine doctor graduates. Provide incentives to medical students to choose family medicine as a career. Increase the number of residency positions. Pharmacy prescribing is convenient but it’s not a substantive solution to our healthcare crisis and there are some legitimate risks.
Hi Dr. Leighton,
Wonderful of you to take the time to engage with our article and to address some very important points.
1) Luckily, pharmacists are acutely aware of the risks of antibiotic resistance due to overprescribing. This is why pharmacists play a central role in antimicrobial stewardship programs across Canada. Pharmacists also usually have the most updated list of medications for their patients and are able to make accurate, data-driven decisions.
2) Please refer to this Ministry of Health communication for details (https://files.ontario.ca/moh-executive-officer-notice-en-2023-09-25.pdf) – in short, Yes – notification of the eligible person’s primary care provider is essential as would be expected to ensure the continuum of care.
3) By empowering pharmacists to manage and treat uncomplicated conditions, primary care prescribers, such as family physicians, are afforded the bandwidth to focus on more complex and critical patient issues. This not only optimizes the use of healthcare resources but also ensures timely care for patients, thereby alleviating undue pressures on an already strained primary care system.
4) Pharmacists, much like physicians, operate at the intersection of patient care and business, masterfully navigating the delicate balance between ethical responsibility and the monetization of their clinical roles. Their primary allegiance is to patient well-being, ensuring safe and effective medication use, while also considering the economic aspects of their profession. Through their extensive training, pharmacists are equipped with the skills to make patient-centered decisions, even in the face of potential monetary gains. This dual commitment underscores the integrity of the pharmacy profession, ensuring trust and fostering therapeutic relationships with patients.
Moreover, in Ontario, pharmacist prescribing will be directed by evidence-based algorithms, meticulously developed with input from a multidisciplinary team of policy decision-makers and diverse healthcare providers. This collaborative approach ensures that prescriptions are both clinically sound and tailored to the unique healthcare landscape of the region.
https://www.ocpinfo.com/wp-content/uploads/2022/12/treating-minor-ailments-infographic.pdf
Lastly, pharmacy prescribing is not the only answer and cannot be a stand alone solution. Addressing the healthcare crisis demands a multifactorial approach that transcends traditional methods. No single solution can tackle the intricate web of challenges—from escalating costs to disparities in access and the ever-evolving landscape of medical technology. Innovative care models, robust health policies, and community-based interventions must work in synergy. Collaboration across sectors, integrating technological advancements with grassroots initiatives, and prioritizing patient-centric care are paramount. Only by harnessing a diverse toolkit of strategies can we hope to create a resilient, inclusive, and sustainable healthcare system for all.
“By empowering pharmacists to manage and treat uncomplicated conditions, primary care prescribers, such as family physicians, are afforded the bandwidth to focus on more complex and critical patient issues”
This is absolutely false despite it being the narrative parroted everywhere by everyone except physicians. It is a recipe for family physicians working harder for less $ and dealing with the extra paperwork sent in by pharmacists, in the name of continuity of care, for free. More administrative burden…less pay. This will absolutely not make things better for family physicians and will contribute to the avoidance of and the exodus from community-based family practice.