Pharmacist Privileges (was Re: The AMA goes QUACK, QUACK, QUACK) 
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 Pharmacist Privileges (was Re: The AMA goes QUACK, QUACK, QUACK)


> Obviously, when the patients pain quality changes, that would be the
>point where referral would be warranted.  Again, this would be routine
>pain management care.  Uh... how are you qualified to tell when a dose

This is neither "obvious" nor "routine" to me.  If you neglect to
perform a physical exam and order appropriate labs,  you could
miss an obstructed bowel, a perforated bowel, ischemic bowel,
or numerous other problems.  _* Especially _* in the case of a patient
with known malignancy, pharmacists are unqualified to manage
pain therapy.

>of narcotic has caused unacceptable respiratory depression?  You have
>learned to look at a number of specific things... respiratory rate,
>depth of breathing... this is not an extremely difficult thing to do.

You are right; it is not extremely difficult.  But it does
require hands-on clinical experience which cannot be gotten
from a  book.   Pharmacists are _* not *_ qualified to assess
a patient's respiratory status.

>Yes, but it can be an extreme inconvenience to do so for both myself, the
>patient, and the physician I call over to sign the prescription that
>I write. It is inefficient and unnecessary.

Just ask the physicians you work with to prepare standing orders
allowing you to manage coumadin dosing; no change in laws or
inconvenience is necessary.

>I'm not qaulified to determine complications vs. routine pain. However,
>I can manage the pain therapy. Again, I am not substituting for a
>physician here, I am managing the pain therapy.

If you are not qualified to distinguish between routine post-op
pain and an operative complication, then you should not be
functioning independently here.  If the physician assessing the patient
subsequently wants you to manage the pain he deems to be routine,
he can currently delegate that authority to you and have you sign
his name.  No change in laws necessary.

>If the patient goes into respiratory arrest, I know BCLS
>as well as anyone. :)

But do you know the non-pharmacologic portions of ACLS as well?
When was the last time you intubated an actual patient?  Have
you *ever* done that?

>visit? no. I think I can detect a change in serum creatinine adequately.

Yes, you can detect a change in serum creatinine. Just read the lab results.
But do you know how to perform a physical exam to assess the significance
of the serum creatinine change?

>And I believe checking a pulse and BP, and doing an adequate medical
>history would be adequate for most hypertensive patients. If something
>is out of the ordinary....turf to a physician.

What is an adequate medical history?  When were you trained
to do that? How much experience do you have?  

>I am not advocating across the board- uncontrolled prescribing by
>pharmacists. But I can tell you that we can do a better job of
>prescribing than most physicans can. There are a few studies out there
>to prove it.

Please cite the studies.

I acknowledge you very well might be right that pharmacists
can _prescribe_ better than most physicians.  But pharmacists
are rarely qualified to _diagnose_ or to _assess_ the clinical
response to therapy.  And _those_ are the reasons why medications
are given prescription status.

>BTW, I don't know if you are aware of this, but clinical pharmacists
>routinely see patients in the VA system as primary care providers. They
>usually are involved in clinics with a physician nearby, and the one

Then they can prescribe without any change in laws.. they
are operating similarly to NPs or PAs under supervision...
I see nothing wrong with that at all.

>I guess I could ask the same questions of a physician. How are you
>qualified to determine if this dosage adjustment for this aminoglycoside
>is appropriate? How are you qualified to dose this anticonvlsant that has
>   nonlinear pharmacokinetics? How are you qualified to choose this
>third-generation cephalosporin to treat this infection? How are you
>qualified to use this new antihypertensive agent that you have only
>"heard about" from a drug rep? How are you qualified to determine if
>this patient is experiencing aminoglycoside nephrotoxicity?

I am qualified because I not only took pharmacology but also have
had years of hands-on training in medical school and residency.
Even though there is much I do not know, I do have explicit
and extensive training in pharmacology and I keep current
through reading journals.  A pharmacist, on the other hand,
is in no way trained to perform a physical exam or to diagnose;
neither can these skills be learned from a book.
Richard Kaplan M.D.           Medical Software Exchange BBS
806 2nd St. SW # 104          (507) 281-1989 14,400 HST
Rochester, MN  55902          (507) 281-1689 Voice

Tue, 11 Jun 1996 11:58:50 GMT
 [ 1 post ] 

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