Pharmacists to play expanding role in primary care and the “medical home”

By Alex McEllistrem-Evenson, Editor, Health Workforce News

In the eyes of the layperson, pharmacy is not a particularly glamorous profession. While it’s difficult these days to turn on a television without coming across a show depicting courageous physicians and nurses saving lives in dramatic fashion through pure ingenuity and sex appeal, representations of pharmacists are comparatively rare. And while it would be a stretch to say that pop culture accurately reflects public sentiment of any profession, it is worth noting that when pharmacist characters do surface in television and film, they range from being slightly-off-center and quirky (Ned Flanders in The Simpsons, for example) to outright sociopathic (think George Williams in Desperate Housewives).

Attributable, perhaps, to their exclusive access to powerful pharmaceuticals and/or the fact that the work of a pharmacist is commonly associated with processing prescriptions and counting pills in a retail setting, these stereotypes are actually a significant point of concern with those invested in growing and promoting the profession.

According to Anthea Francis, Director of the Section of Inpatient Care Practitioners with the American Society of Health-System Pharmacists (ASHP), “one of the issues plaguing pharmacy is the [mis]perception and the public’s understanding and comprehension of the different practice settings that a pharmacist is in.” Francis, who was employed at Johns Hopkins as a practicing pediatric pharmacist for almost two decades prior to her work with ASHP, describes pharmacists as the “unsung heroes of health care.”

She has plenty of stories to back up her claim. “I advocate for the front-line pharmacist,” she states: “that person who is in the hospital at ten o’clock on a Friday night when all of the clinical specialists have gone home, and the snake bite victim comes in, and we have to get that anti-venom in there within a certain period of time. That’s the pharmacist on the front-line. That’s your soldier.”

The ASHP, a national non-profit organization representing more than 35,000 members, focuses directly on the professional betterment for the kind of pharmacist Francis describes: essential health care providers within “every kind of health system,” Francis states, citing “rural health clinics, critical access hospitals, big university academic center hospitals,” and more. Far more than stereotypical “pill-pushers,” health-systems pharmacists consult with physicians and patients in a clinical setting to provide complex medication therapy management (MTM) requiring extensive training in every aspect of medication.

Francis and her ASHP colleagues are involved in much more than debasing negative stereotypes of pharmacists and informing public perception. “The fact of the matter,” she states, “is that most medical errors that happen are associated with medications. There are no other professions that have the training and knowledge base that pharmacists have. We are, without doubt, the drug information resource. The pharmacist should be an integral part of the health care team.”

In a workforce climate which emphasizes the importance of primary care services, pharmacy is a profession both in high demand and undergoing a process of evolution. Lynnae Mahaney, President of ASHP, states “absolutely, positively” that pharmacists can help to alleviate the burden on primary care physicians, for whom demand far outpaces supply. “This goes very closely with the medical home model,” states Mahaney. “The medical home model includes health care providers of all the different disciplines who work as a team to take care of the patient, that the physician will be the team leader, but all of those other disciplines will be responsible and accountable for their portion of the care with the patient and be part of the coordination of care. The pharmacist’s expertise is drug therapy management. Definitely, in this evolution with both health care reform and the primary care shortage, the pharmacist will play an integral role here.”

When discussing the topic of the primary care medical home, Francis is even more concrete. “The June 2008 report to Congress from the MedPAC advisory commission about reforming the primary delivery system (full report / summary) stated that a medical home’s responsibility for patient medication reviews should be coordinated with a pharmacist. The whole idea is coordination of care: when pharmacists and MTM involvement became integral to this whole medical home model it was demonstrated that a pharmacist’s value is crucial.”

The prospect of a primary care model which casts pharmacists as the medication expert on a team of health care providers is an attractive one for Francis and her colleagues. “If it has to do with medication, it is imperative that the pharmacist is the primary person,” states Francis. “If a pharmacist is viewed as an integral part of a primary care team, then that individual is going to become the go-to person when it comes to drug therapy issues, pharmacotherapy, medication safety, adverse drug reactions, drug interactions, food and drug interactions, whatever the case may be.”

The biggest obstacles to adopting this kind of a patient-centered care model, however, may be systemic. In a financial structure which provides payment for services, Francis observes that pharmacists are too-closely associated with the prescriptions they fill, as opposed to the other services, patient care, and information they provide.

“Historically, pharmacists have been associated with a product,” she states. “That’s why people tend to think of the pharmacist as the licker, the sticker, and the pourer. You’re licking the back of the sticker to put on the medication bottle, you’re pouring from one to another, and that’s what the public sees. What the public doesn’t realize is that when you take in a prescription and the dose is too high, the pharmacist is the person who calls the physician and recommends that he or she make an adjustment.”

Pharmacists, in Francis’s opinion, need to be paid for cognitive services – advice based on their knowledge, expertise, and training – in the same way that physicians or attorneys are.

“Would you think twice,” Francis asks, “about paying your attorney a retainer for services? The attorney hasn’t given you anything. The attorney has given you advice. You go to a physician and pay for that doctor’s visit. You may or may not get a prescription. What do you pay your pharmacist when you go to your pharmacist and say ‘I’m having an issue with my medication,’ whether you’re in a hospital or not?”

“That would be the barrier in terms of incorporating pharmacists into the whole primary care medical home model,” Francis continues, “even though research has demonstrated that their incorporation into it is a high success and that when medical teams are multidisciplinary in their focus, it’s all in the best interests of the patient. When you incorporate your nurse, your physician, your pharmacist, and your physical therapist and dietitian when appropriate, it’s much better than when we’re all working in separate silos.”

Francis uses a striking analogy to drive her point home regarding the importance of utilizing and recognizing a pharmacist’s expertise and training within primary care services. “If your heart is in bad shape, are you going to a podiatrist? Of course not. So why on earth would you go to a physician to ask about your medication?”

“Think about the difference between the kind of pharmacology education that a physician or a nurse gets versus what a pharmacist gets,” Francis explains. “A pharmacist has six years of education in all aspects of medication. Not just pharmacology, but biomedicinal chemistry, pharmacoeconomics, pharmacokinetics, everything. And this is prior to post-graduate training; pharmacists do residencies as well. A doctor, on the other hand, receives at most maybe a year of pharmacology; a nurse, maybe a semester. That person isn’t keeping up through continuing education with medications and drug therapies that are constantly coming out, either, the way pharmacists are required to do.”

While pharmacists are receiving increased levels of recognition in certain arenas, such as medical home models and primary care, the ASHP and other professional advocacy organizations have plenty of work to do. Mahaney stresses complicating factors in the area of pharmacist specialization, clarifying that in recent years, national funding was cut for second-year specialized pharmacist residency (PGY2) programs, effectively reducing the numbers of pharmacists who choose to specialize. “Oncology, informatics, intensive care, cardiology, any specialized area you can think of,” she clarifies. “We’ve been working very hard to try to get other funding sources nationally for this training because it relates closely to where the pharmacy profession is going as a whole. We have very many generalists, and we need those to serve as primary care providers. But we also need pharmacists in these specialized areas because these drugs and disease states are so complicated.”

By all accounts, shortages of primary care physicians and an increasing need for specialized expertise in drug therapy management illustrate the importance of expanding the pharmacist’s roles within both health systems and within common public consciousness. Although pop culture may indicate otherwise, a provider’s penchant for drama and individual courage are not likely to result in positive health outcomes.