Y’know, I was having a chat with one of our elected representatives in the Province of Ontario the other day.She mentioned that the government is going through a process including a white paper on Patients First as a theme moving forward in health care.We chatted for a while about how pharmacists have been…Well, here’s the letter she suggested I submit.Dear Minister,The emphasis of the health system of Ontario on Patients First resonates with my chosen profession, pharmacy. I ask that the incredibly valuable contribution that medications make to the health of the residents of our province be understood in the context of the contribution of pharmacists. Medications do not save lives. Patients need to use them, and use them properly. It also requires ensuring that the best possible medication is used at the right time in the right way matched to the patient’s unique needs.It also requires the patient understanding and appreciating not just how to use the therapy, but the importance of treatment, how it should help, what problems to watch for, how it fits with other treatments, how all conditions must be considered when choosing and adjusting every individual therapy, and even how patients make changes in their health choices and maintain them. And finally it requires following up on how things are working, and continuing to make adjustments to treatment as health status changes over time. And this is not just because they may not work. Any of these gaps not being addressed could harm the patient as well.But there is much more that people need that pharmacists can provide, from chronic disease management services including education, monitoring, and health decision support to collaborating more fully on choice and adjustment of therapies. This should include the input of the patient, but therapy choice input by the patient requires the provision of knowledge and sophistication about the choices to the patient. It means converting the clinical language of pharmacology, physiology, and cost-benefit into a language familiar to the patient. No-one in the health system understands the interaction between medications and the body’s systems, nor the balance of the chances of a treatment helping with the risk of a problem better than pharmacists. That unique understanding translated and transferred to patients is a huge gap that a fully activated patient needs to have addressed.My 32 years as a pharmacist have been spent saving lives and improving quality of life for the thousands of patients I have been charged with helping find better health. In the process of over 10,000 different patient interactions each year in community practice, for thirty years, with hundreds of evaluative assessments each day, coupled with providing everything I do, I have used my pharmacist knowledge in what now counts in millions of times.There are at least 10,000 pharmacists in Ontario involved in direct patient care, with 400 new pharmacists produced each year from our academic institutions, and more coming from other countries to contribute to the health of Ontarians. Calculated another way, there are hundreds of millions, if not in the billions, of pharmacist assessments done each year in this province. And yet still just scratching the surface.My colleagues and I in the profession of Pharmacy have been underutilized over that entire time. We pharmacists have been constrained by a system of healthcare delivery in the province of Ontario that has not come anywhere close to creating an environment that utilizes my knowledge, my skills, and my unique contributions to patient welfare during that time. Notwithstanding that, pharmacists have always provided more than has been recognized, or appreciated, or integrated within the healthcare team and the public consciousness.This evolution of what pharmacists can do to help patients has outstripped even the technology advances of the past 30 years, and the need for bringing it to bear to the demands of our demographics multiplied by the benefit of intercepting health problems sooner and more effectively and efficiently screams for the engagement of pharmacists as never before.The large population of pharmacists available and ready to contribute to health is ready.It is no longer debateable about whether pharmacists can do more as the evidence has continued to mount for decades, and in particular how utilizing pharmacists more than they currently are consistently shows a significant benefit for patient outcomes. Multiple disease states and multiple targets for therapy have repeatedly been demonstrated to be addressed more effectively, including such common and far-reaching issues as high cholesterol, high blood pressure, diabetes, and smoking cessation. Screening for and management of everything from pain and mental health issues to supporting non-pharmacological interventions can be added to that.Of course a large part of the problem is the perception, understanding, and expectations of what pharmacists do. The majority of experience of the public is community practice seen in various types of pharmacy retail environments providing prescription services. The belief that pharmacists simply ensure that the medication that is ordered is the one selected and provided is prevalent even as it is a small part of even the dispensing process, let alone other parts of pharmacist care that are part of what we do. There is an intellectual contribution that is well defined as the pharmaceutical care process that is the core of what pharmacists do, and the launch point for other roles including chronic disease management.Pharmacists are charged with this process of pharmaceutical care, an assessment process unique to pharmacists that evaluates the presence of health problems, checks that treatments exist where they are beneficial, seeks clarification that there is a valid reason for use, and that any treatments are actually indicated for the illness being managed. Beyond that, checking that the treatment is as effective as desired, is the best one based on the patient’s specific characteristics including everything from previous experience to improving other conditions the patient may have. Also, the treatments should not adversely impact each other, nor any other conditions the patient may have. Adverse effects of treatment need to be assessed as serious, manageable, avoidable, or have corrective measures to ensure valid treatments are continued when the problems can be managed. And the largest medication problem of all, failure to adhere to treatment, is addressed with sensitivity to patient specific issues. This includes something as simple as making sure the schedules of medication use fit with the patient’s life patterns to the more complex health choices and behaviours that benefit not only from education by providing information and knowledge, but also understanding and utilizing skills such as motivational interview and health coaching, and behaviour modification with self-care planning that matches with care planning of the illness being treated. Of course recommendations for changes come from these assessments, and should be done collaboratively with the patient and other care providers both because it is respectful of patient autonomy and it provides the best possible outcomes. And then, of course, any changes should be followed up on and refined to best possible outcomes. This is what puts patients first.I work in a complex diabetes program, one of the new CCDCs started 5 years ago to improve the outcomes of patients with multiple illnesses who utilize the health system heavily, and with whom the above assessments are critical with drug therapy problems numbering in the dozens for most patients. It should be noted that these patients are almost always working with a primary care provider, and usually other medical specialties, and other clinics and programs. Most of these problems were previously unidentified, which means in the absence of a pharmacist’s input they would not have been discovered or addressed. My role includes education about medications and the diseases being treated to help patients make informed health choices. I also engage in behavioural interventions including motivational interviewing, health coaching, and collaborative and structured care planning with patients as this is a rare, but effective and proven method to help patients make and maintain effective health choices and changes. I work with the patient, their primary care provider, and the rest of the team collaboratively with the goal of engaging optimal self-management. My patients are fortunate that I work in an environment where those interactions are facilitated. The things I do could be done in community practice and would multiply the impact I have by the thousands, but that work environment does not provide for or nurture the kinds of interventions I provide. As a result, the majority of the population does not receive this benefit.This could all translate to community practice to help patients before they are as ill as the patients that I see every day. However, the system that community practice pharmacists work in including the information they have access to (such as lab results, hospital and emergency discharge reports, other test and consultation report results), integration into the larger health system to receive, track, and evaluate these contributions, referral or rostering for comprehensive and efficient shared care, and compensation mechanisms targeted to these behaviours do not currently exist in Ontario.I also see the sickest of the sick in my practice. And almost all of them would not be as sick as they are if something different had happened in their health past. A large part of that gap could have been filled by using their pharmacist better. I know this because when I find the problem patients say things like:“Why has no-one told me this before?”“Now I finally understand why I should do the things people tell me about.”“Where were you ten years ago?”Ten years ago I was in community practice. I was doing my best to do all of the things I could and should. I didn’t have the tools or the space and time 10 years ago. And that was to the misfortune of my patients who now could ask me the same things.But I still did a lot of good things, continually trying to go beyond what the system recognized, facilitated, and paid for. And a whole lot of my colleagues did as well. But, specifically because it was not recognized, facilitated, or paid for, when the revenues into pharmacy were shrunk, the first things to go would be those very things that patients need and are not getting anywhere else. So my previous workplace closed down. However, I was fortunate to end up in an environment that nurtured those very things. Some other environments like this exist. They are proof that the impact of my profession can be significant. But the large majority of pharmacists do not work in environments like mine. And that is why pharmacists are a largely untapped health resource.This could happen with a model that corrects the inefficiencies and inequalities of the current system. Pharmacists are a learned profession as exemplified in the entry level Doctor of Pharmacy degree that has recognized a level of academic commitment and achievement consistent with the honorific, as well as the expectation to meet that responsibility of pharmacists as outlined in our Code of Ethics. Pharmacists require a supportive work environment to meet those obligations, and those obligations are based on the central dictate of our Code, which is to put patients first. It starts with understanding better how much pharmacists can contribute. It also means that those capable of meeting those demanding requirements are limited in number, and to attract the best of them means ensuring the pharmacy profession is a place they want to be. This is as important to the public as it is to the profession because we both need to continually elevate the level of contribution to the health of Ontarians.Pharmacists are, in number, only exceeded by Nursing and Medicine. Our singular facility with drug therapy and all of its elements in a health system that expects medications to provide health and ultimately economic benefits by lowering other service utilization has been underused, which means patients are getting sicker and dying every day but for the failure of the system to understand and use my profession. Again, hundreds of problems identified, or better yet, avoided by each pharmacist multiplied by the thousands of pharmacists in the province every single day. It happens already, but is nowhere close to being augmented and taken advantage of.It is time for a highly intelligent and motivated group of professionals to bring their entire skill set to a long list of unaddressed problems that they are specifically and uniquely trained and qualified for. It is a contribution that is definable, measurable, and available. Please consider my profession for what it is instead of what it has been presumed to be for years. Help put patients first by helping all of my colleagues put patients first by changing the understanding and expectations of pharmacists. The goals of a health care model that requires activated patients, timely interventions, and the right provider to the right patient at the right time would demand that pharmacists be used differently than they are now, because the current state, and indeed the current conversations about how pharmacists work in the health system need to change in order to put patients first.The individual I was speaking to has been the health critic in Parliament for three terms or so. She was very interested in this.She mentioned meeting with pharmacy representatives at least once a year. She asked me why she hasn’t heard this kind of thing before.And before everyone starts blaming others, let us only be informed by what happened before, and not impeded by it.Maybe we should all get together and tell…everybody.Of course, Please let me know if my colleagues in this province, and across the country share my belief in the above. If it isn’t then I will shut up.Well, probably not.Ken Burns is a pharmacist at the Diabetes Care Centre at Sudbury Regional Hospital.