Pharmacy pet peeves

They dispense the meds you prescribe and, depending on what province or territory you’re in, they may also assess your patients’ ailments and generate their own prescriptions and treatment plans. Canada’s pharmacists have staked their position as the country’s most accessible healthcare providers. But some doctors wish pharmacists would do less of certain things. A poll that the Medical Post ran recently on CanadianHealthcareNetwork.ca—the digital platform we share with our sister publication Pharmacy Practice + Business—found doctors were unhappy with some pharmacist behaviours. On top of their list of pet peeves: asking seemingly unnecessary questions about the details of a prescription. Next was sending faxed notifications about extended medications already filled by the doctor. Third was suggesting over-the-counter meds or other remedies to patients who should really see a doctor. Another pharmacist no-no for doctors was substituting brand-name drugs specified on the script with generics. What else? In addition to answering our poll, some doctors posted comments online that described in further detail pharmacist behaviours that irked them. “If they are going to be ‘primary care providers’ they should keep their own records and take full responsibility for the changes they make,” wrote Dr. Carmen Eadie, a family doctor in Surrey, B.C. “I shouldn’t be asked to sign off on what they are doing. . . without some form of remuneration.” Dr. Anne Sorensen, a family doctor in Oshawa, Ont., lamented the growing volume of faxes she’s getting these days from pharmacists. “I am generally thankful for pharmacy support, but lately have been receiving faxed refill requests for medications with one medication per page—and for one patient, 12 separate faxed sheets!” she posted on our poll page. ‘No sense’ Dr. Natalie Leahy, also an Oshawa family physician, noted that most of the requests she gets from pharmacists still come in by fax, even though she switched to e-prescribing three years ago. “It makes no sense!” she added. Other doctors responding to the poll complained about what some pharmacists aren’t—but should be—doing as part of their practice. “Not logging the refills on my prescriptions, then faxing three months later asking for a refill when there should have already been several logged,” wrote Dr. Andrea Delrue, an internal medicine specialist in St. Catharines, Ont. “You (pharmacists) have a drug database, why don’t you suggest an alternative?” posted Calgary family doctor Dr. Reena Suri, who complained about pharmacists informing her a medication she ordered is backordered and then asking her to prescribe an alternative drug. Meanwhile, over in London, Ont., Dr. J. David Spence wished pharmacists would inform him first if a patient previously had a limited-use (LU) code for a medication before asking him to renew the same drug. Dr. Jabir Jassam in Ottawa said he doesn’t like it when pharmacists hold a medication until they get an LU code. More info So what’s behind these actions that bug doctors? The Medical Post asked two pharmacists—one in Alberta and another in Ontario—to explain the possible reasons behind some of the pharmacist pet peeves doctors identified in our poll. Kristen Watt, a pharmacist owner in Southampton, Ont., and pharmacy school lecturer at the University of Waterloo and University of Toronto, addressed the top complaint: pharmacists asking for prescription details that physicians may deem unnecessary. “We can’t do our job effectively and safely unless we have all the information we need,” she said. “One of the most common causes for medication errors in pharmacy is due to lack of understanding of the indication.” As an example, Watt cited a patient with a prescription for Keflex (cefalexin). She learned after asking the patient that the medication was to treat a cat bite. “Keflex is not first line for a cat bite,” Watt said. “If I had just assumed it was for a skin or soft tissue infection, the patient could have suffered serious side-effects. Mistakes can and do happen on the physician’s side as well, so pharmacists are another layer of safeguard for patients.” Dr. Janice Armstrong, a retired family doctor in Toronto, voiced similar views when she responded to our poll. “I find it incredible that doctors are complaining about pharmacists double-checking any questions they have. What this means is that when we (inevitably) make a mistake it will be corrected. In my experience, the problems arose when the pharmacist didn’t double-check and misinterpreted the prescription.” One such misinterpretation of an antibiotics prescription in Quebec led to increased international normalized ratio and nosebleed in a patient undergoing hemodialysis. The prescribing physician had scribbled “SS” on the prescription to denote single strength. The pharmacist, who was not familiar with the acronym, assumed the doctor meant super strength and dispensed the double-dosage version of the drug—a mistake that could have been avoided if she had checked with the doctor. Limited-use codes LU codes seem to be a bone of contention between physicians and pharmacists. Pharmacists need this code, said Watt, so doctors should just provide it to them when they issue the prescription. “We can’t bill the (provincial drug benefit plan) if we don’t receive the LU code at the outset,” she explained. “If we give the medication to the patient assuming we will get an LU code and we end up not receiving the code, then we’re either on the hook to pay or we risk audit and claw back. We should not be asked by the physician or anyone else to provide medication for free.” Patients also have the option to pay for the meds if they don’t want to wait for an LU code. But in most cases, said Watt, they’d rather not pay out-of-pocket. “Oftentimes these patients have already waited weeks to get an appointment with their doctor, so waiting another day or so for their physician to provide an LU code is likely not going to harm the patient,” she said. “We’re not trying to be gatekeepers, we’re just working within the system. It’s no fun for us either.” Out of stock Melanie Henderson, a pharmacist in Fort Saskatchewan, Alta., said that when it comes to back-ordered meds, the first—and ethical—course of action at the pharmacy where she works is to call other pharmacies to see if they have the drug in stock. “If no one has it and we are competent to make a therapeutic substitution we do that and notify the doctor by fax or PrescribeIT of the change,” she said. But when the pharmacist isn’t qualified to make a therapeutic substitution, “we contact the doctor for an alternative.” Not all pharmacists in Canada are qualified or authorized to recommend an alternative for out-of-stock medication. In Ontario, for one, pharmacists can’t do this and must ask the prescribing doctor for permission to change the drug. Switching to generic medications, the number four complaint in our poll, is another matter, said Watt. “We have to offer them. Ontario legislation says we have to offer the patient the cheapest version of a medication. And with a few exceptions, generic drugs are the equivalent of the brand name drug.” Don’t take that drug Another pet peeve cited by one doctor stemmed from some pharmacists telling patients not to take a physician-prescribed drug or “over-exaggerating the side-effects” to the point where a patient gets too scared to take the meds. Watt said this pet peeve “goes both ways.” With a growing number of pharmacists now authorized to prescribe for certain ailments, she’s hearing more complaints from colleagues about doctors warning patients about medications prescribed to them by pharmacists. “So this problem isn’t always about a physician questioning what a pharmacist is prescribing—in some cases, a physician may tell a patient not to take a medication another physician told them to take,” said Watt. “What’s really important to understand is we’re all autonomous prescribers. It’s all about autonomy in our practices and we all have our own professional opinions.” In her own practice, added Watt, when she doesn’t agree with a prescription she’ll get on a call with the prescriber—whether that person happens to be a physician or pharmacist. “I’ll speak with the prescriber so we can get on the same page and present a united front to the patient,” she said. “But it’s not my job to agree with the physician. My job is to do what I believe, as a trained healthcare professional, will be best for the patient.” “I am generally thankful for pharmacy support, but lately have been receiving faxed refill requests for medications with one medication per page—and for one patient, 12 separate faxed sheets!” Valid annoyances Pharmacists ordering point-of-care blood testing—typically for A1C and lipids—then sending the results to the doctor for review? Restricting patients to monthly refills so the pharmacy can collect recurring dispensing fees? Doctors aren’t wrong in being angry about these pharmacist behaviours, said Watt. “There are corporate pressures that drive patient interactions sometimes,” she said. “Unfortunately, there are pharmacists who are beholden to their employers and that makes it really, really challenging for them to practice. And it’s not so easy to just tell them, ‘Well, don’t work for the big-box chains,’ because not everyone has a choice.” As for those multi-page prescriptions—where each medication for the same patient was transmitted on a separate fax sheet—Watt said that’s likely the fault of pharmacy software. Just as some doctors have problems with their EMR, some pharmacists also have to work with buggy software. So why can’t pharmacists ditch the fax and switch entirely to electronic communications? Why insist on paper prescriptions? Watt said many pharmacists, including herself, are pushing back on e-prescriptions because of concerns that pharmacists will end up paying to use PrescribeIT—the national e-prescribing service developed by Canada Health Infoway—while physicians can continue using it for free. “When it goes to a pay-per-use model and I’m asked to pay for it but physician prescribers are not, I will stop using that system,” said Watt. “Why should pharmacists be the only ones who have to pay to use it?” What’s an MD to do? Dr. Ron Witzke, a surgeon in Medicine Hat, Alta., views pharmacists as “by and large . . . a real benefit to my practice—checking for drug interactions, advising better alternatives and teaching patients.” But, he added, “I do find it frustrating when one decides to alter dosage without letting me know. For example, I usually prescribe 3 mg Ativan S/L prep for vasectomies and have had a couple of pharmacists decide this was too large a dose and tell patients to take just one pill.” What’s a doctor to do when this happens? Dr. Witzke said his first reaction is to be “affronted and angry.” But after considering the pharmacist’s motives—patient safety—he’ll call the pharmacist to discuss the alteration. “The dose I use is based on 45 years of doing vasectomies on these young men, who all say, ‘I don’t know, doc . . . those pills you gave me aren’t doing a thing!’ and whose cremasteric reflex seems undamped,” said Dr. Witzke. “At the end of our conversation, (the pharmacist) understands why the dose is given and the necessity and professional responsibility to contact me before making such a change.” Can’t we get along? Pharmacists want to be part of the healthcare team, said Henderson. “We want to work with them,” she said. “Call us, reach out. Add an extra note to a prescription if you need to give us further information.” Many doctors she deals with already do these things, added Henderson. “It just takes time and a professional relationship based on trust.” “Physicians need to know that we are here not only for the patient, but for them as well,” she said. “My entire day is focused on ensuring that the doctor’s plan is effective and carried out. . . . We can help them with drug information, alternatives on drug outs, third-party billing and coverage information. They hopefully see us as a team and know that we want to work with them.” Watt said new and upcoming pharmacists have been trained to focus more on delivering care and less on dispensing. They’re deeply knowledgeable and are coming into practice as therapeutic partners in patient care. “That’s the paradigm shift,” said Watt. “Physicians have to be ready for it because it’s already here.”

Pharmacy pet peeves

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