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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1515762/pdf/califmed00068-0052.pdf
Medicine in Society
Part III: A Role for Medicine inModern Society
MALCOLM S. M. WATTS, M.D.San Francisco
THE PRECEDING SECTION of this inquiry into "Medicine in Society" drew attention to some
vast and largely irreversible social, eronomic and political effects of the application of scientific
advances in both medicine and society. Specialization in the function of individuals, a necessary
consequence of this great progress, produces greater social, economic and political interdependence
within and between both medicine and society. The problems created by these changing
relationships are many and as yet they are poorly understood. But they clearly affect both medicine
and our culture in most fundamental fashion. A few of the "dimensions" of modern medicine in
modern society were briefly discussed.
These new interdependencies among people and among functions are not to be escaped in an
age dominated by science. The net effect has been to produce a complex system, which like any
complex physical, biological or social system, must sooner or later develop some order and
direction within itself if it is to perform effectively. Much of what is at stake in this development
is the role which the individual as such will play. In medicine, the issue is found in the survival
This is part III of a communication in three parts. Parts I and II appeared in the December 1964 and
January 1965 issues. of individualized medical care directed by a physician whose first interest is
his patient versus depersonalized statistically oriented mass medicine directed by the government or
someone else "in the public interest." In society, the issue can be expressed in such terms as the
social trend toward the security of conformity versus the protection and enhancement of freedom
for the nonconformist; the economic concepts of free-enterprise versus the planned economy of
socialism; or, in the political sphere, the extent to which the minority will be compelled to submit to
the will of the majority, or perhaps vice versa. For many reasons medicine is vitally concerned with
all these problems. The preservation of freedom of expression and freedom of action for the human
individual be he doctor, patient or citizen, as well as the inescapable need to find means to give
order and direction to an increasingly complex biosocial system are each of the greatest importance
to human health and to good medical care. The broad social responsibility of modern medicine in
this modern society now requires re-examination. So far medicine has offered surprisingly little in
the way of leadership or constructive advice. Yet the role which medicine will ultimately play will
surely depend CALIFORNIA MEDICINE 133 upon the effectiveness of its leadership and its
performance at this time.
2. Progress
The commitment "to promote the art and science of medicine" is fundamentally a commitment to
progress. To the physician progress means advances or improvement for the human being, for
society, or both, in a biological and cultural sense. This meaning does not refer to the "progress" of
any conceptual social, economic or political theory, doctrine or belief in the sense in which the
words "progressive" and "liberal" are commonly used in the present scene.
The physician-scientist knows that biological, scientific and cultural progress is based on the
outcome of many trials of new and different ideas, rather than conformity to conceptual theory.
Most of these experiments fail, but some succeed. Those which fail are a price which is paid for the
advantages gained from those which succeed. Progress is most rapid when there are many
experiments. It is slower when they are restricted and infrequent. Thus, medicine's commitment to
progress through experimentation places it not only squarely in the social struggle between
individual freedom and collective conformity, but also between advocates of the relatively
unplanned free enterprise system, and those who would plan and carefully regulate society.
Medicine, therefore, also finds itself in the midst of the semantic confusion which currently
surrounds the use of the words "progress," "liberal," "freedom," "security," "free enterprise,"
"socialistic," "conservative," "reactionary" and the like.
In its commitment to progress through experiment,medicine also maintains its primary concern
with what is best for the individual. This is true for scientific experiments where careful attention is
given to the safety and welfare of the individual. It has also been true for experimentation and
research in methods of financing medical care and of delivering medical services, where it has
resisted and opposed experiments which it felt could not be in the best interest of the individual; or
which would lead to regulation, restriction and control, which would in turn prevent further
experimentation; or which once undertaken could not be either abandoned or reversed. It is this aim
which has placed medicine in diametric opposition to much present day "progressive" and "liberal"
thinking which in reality is perhaps more truly "reactionary," in the sense of inhibiting progress,
than "liberal."
Is it not this support of freedom to experiment and freedom to progress which makes a free and
outspoken medical profession so often an anathema to those who would impose their conceptual
sociologic, economic and political theories upon society?
Perhaps medicine can capitalize to a greater extent upon this commitment to true biological and
cultural progress.
5. Medicine has unusual communications resources. The medical profession has direct and
intimate contact with all cultural groups. It has roots and branches which reach into virtually every
aspect of society. Its members are skilled in convincing individuals to do what is in their best
interest. Its subject matter is readily adaptable to and widely used by mass communications media.
Communications channels exist between doctor and patient, between doctor and citizen and
between organized medicine and the public.
6. Medicine and the public have a common interest in the human individual, his health, his
welfare, his individuality and his freedom to progress. Public opinion and the voter at the ballot
box are strong determinants in the evolution of our society. The voter and public opinion are
influenced by emotion, beliefs, information, personal experience and by what other people think.
These influences are transmitted by communication. Medicine and the public have a common
interest which can provide the framework for the communication of information, experience and
advice based on competence in the broad field of human biology.
E. Conclusion
In conclusion it is suggested that organized medicine address itself to the responsibilities of modern
medicine in modern society, and arrive at a determination of the role which it wishes itself to play.
It should decide whether it will perform as "physician" to society or abdicate this essential function
to the most powerful contestant. It should also decide whether it will assume the responsibility of
resolving the social problems resulting from scientific progress in medicine and in society by
strengthening order, direction and leadership within the dimensions of the free enterprise system or
whether, through disinterest, disunion, procrastination or failure to perform, it will in effect bring
about government regulation and control by its own default. The future complexion, not only of
medicine, but of our society itself, may very well hang upon these decisions and what is done to
implement them.
Life is short, and Art long;
the crisis fleeting; experience perilous, and decision difficult.
The physician must not only be prepared to do what is right himself,
but also to make the patient, the attendants, and externals cooperate.
— First aphorism of Hippocrates, circa 400BCE, from the Hippocratic Corpus online (translated by
Francis Adams)
Desired behaviour
Interviews with patients have indicated that the ideal physician would be confident, empathetic,
humane, personal, forthright, respectful, and thorough. Incorporating clues to such behaviors may
create a better doctor-patient relationship.
Undesired behaviors are essentially the opposites, specially being insensitive or disrespectful, e.g.
arrogance in dismissing the patient's input, disinterest in the patient as an individual, impatience in
answering a patient's questions or callousness in discussing the patient's prognosis. Another
undesired behavior is seemingly providing excellent service in the original visit but then failing to
meet the created expectations about the speed or quality of follow-up service.
Still, when having to choose between high technical quality and high interpersonal quality, two
thirds of patients choose high technical quality. Nevertheless, the level of technical quality may be
hard for a non-professional to assess, which in reality results in a tendency of patients to primarily
judge physicians on behavior. wiki pedia
--------
Your first question: What are the duties of an ideal doctor towards his patients & towards his
profession. Towards your patients you must work towards the betterment of their health. You must
work with your patients as partners in that goal. It is your job to explain, to the best of your
understanding, what health threats they face, and provide them the options (giving both the positive
and negative consequences) for each option that they have. You must respect their decisions,
whether or not you agree with them, and you must maintain confidentiality about most things that
the patient tells you. The duties towards your profession include working together with other
physicians to create a healthier community, country, and world for everyone to live in.
Your second question: What is the role of a doctor in our society. This answer is fairly
straightforward. Doctors work to increase the health of their patients. This includes listening to
emotional stresses and helping to alleviate them if possible. Society tends to hold physicians in high
regard. Because of this, doctors have influence (perhaps unfounded) in many areas. Doctor should
be very careful not misuse the trust placed in them.
Your third question: How can doctors contribute to improving healthy living conditions & how can
a doctor contribute to effection political decisions that effect medi-care and medical conditions in
hospitals or other ethical decisions take by our governments. Again, doctors have a lot of influence
in society. It is not usually part of a doctor's job to be a politician, and so to be politically active,
doctors must use their free time if they want to work for improvement. Most doctors work very long
days, and therefore do not have time to use this influence to bring about improvements. However,
those that do tend to have a big impact. Some doctors write letters to the government, or even meet
directly with politicians. Others work hard in their own communities, volunteering at free clinics for
poorer patients. There is a lot that a doctor can to, but it can take a great deal of energy to
accomplish these things. It is important to note here, that anyone can have a large impact of politics
and in their own communities. It is my view that everyone should work towards improving their
communities.
Your Fourth question: Why does any ideal doctor wanted to become a doctor. I want to know what
is the motivation that motivates most people to study medicine (Not good income or stable life).
An ideal doctor wants to become a doctor because they enjoy working with people and they find
medicine very interesting. There are many jobs in which you would get to work with people and
being a doctor is one of them. I will not say that an ideal doctor wants to help people, because I
think that most people want to help others, and accomplish it in a variety of different ways. For
example, a scientist may discover a new medicine that cures many more people than one doctor
could help during his life time. A politician may negotiate a peace treaty that saves millions of lives.
Certainly no typical doctor could see a million patients in his life time. There are many ways to help
people, but they do not always allow the helper to work directly with people.
Being a doctor is like being a mechanic except that a mechanic works to fix a machine and a doctor
works to fix a person. Because people are far more complicated and valuable than most machines,
there is a higher standard demanded of doctors than of mechanics. The training is a lot longer, for
example. In the end, however, society needs mechanics as badly as it needs physicians, teachers,
scientists, and everyone else.
It is important to be humble about being a doctor. Being a doctor does not make a person smarter,
wiser, kinder, or in any other way better than others. Unfortunately many people do not realize this.
Sometimes patients will forgive a doctor for acting badly simply because they are a doctor.
Sometimes doctors become arrogant because people give them so much respect without needing to
earn that respect. Doctors are normal people who have extensive training in the diagnosis and
treatment of disease, and they usually work very hard with good intentions. I think that most people
work very hard with good intentions whether they are a doctor or not.
Now I will pick out one attribute that deserves emphasis in physicians. While compassion is a virtue
all people should practice, when doctors do not practice compassion, they can become very cruel. I
have seen very good doctors, who are also good people, forget to be compassionate with their
patients and end up being cruel.
While it is easy to be compassionate to most children, and also to people who are kind and good, it
is more difficult to be compassionate to people that you have difficulty liking. For example, my first
patient was a prisoner that had committed many crimes. While we both spoke English, the way we
spoke it was quite different and I had trouble communicating with him over the two weeks that he
stayed in the hospital. He was often very angry. Yet it was important for me to continue giving him
the best care that I could while he healed from the surgery that had been performed on him. When
the patient was ready to leave the hospital we needed to write him prescriptions to control the pain
he had. The doctor I was working under was angry at the patient and wanted to give him a weak
medicine that would not control his pain as well as a stronger medicine. After I argued with this
doctor, he changed his mind, and remembered to be compassionate.
I have also seen a great difficulty that many doctors have with being compassionate with psychiatric
patients. If a person is under tremendous emotional stress, they can feel pains in their bodies. The
pain is very real to these patients, but no pain relievers can make the pain go away. Because these
patients can feel the pain, they are offended by the idea that the pain is generated in their brains
rather than in the peripheral nerves of the body. Because of this misunderstanding, it can be very
difficult to convince some patients that visiting a psychiatrist would help eliminate their pain.
Doctors sometimes become tired of these patients, and lose compassion for them.
In your career you will encounter all kinds of people. Some of them will make you angry, but it will
be very important not to judge them, and to remain compassionate. It will be your job to help them
as well as you can, no matter how badly you dislike them. I wish you luck in your studies, and I
hope that find enjoyment in your work as a doctor.
http://www.madsci.org/posts/archives/nov2001/1005776941.Me.r.html
PHARMACY
Though environmental factors, like the increasing number of senior citizens or the advancements in
pharmaceuticals, have played a role in encouraging this evolution, the change can primarily be
traced to the passage of the Omnibus Budget Reconciliation Act of 1990. This legislation, in part,
required pharmacists to perform a drug use review, patient counseling and documentation in some
form of patient profile.
According to Stephen L. Foster and Jerry R. Phipps in their paper "Counseling on new drugs," the
law required pharmacists to screen for:
• Therapeutic appropriateness.
• Over- and underutilization.
• Appropriateness of generic products.
• Therapeutic duplication.
• Drug-disease contraindications.
• Drug-drug interactions.
• Incorrect drug dosage or duration of drug treatment.
• Drug-allergy interactions.
• Clinical abuse or misuse.
In addition, patient consultation was mandated to include:
• The name and description of the medication.
• The route, dosage form, route of administration and duration of therapy.
• Special directions and precautions for preparation, administration and use by the patient.
• Common severe side effects, adverse effects, interactions or therapeutic complications that may be
encountered, including their avoidance and the action required if they occur.
• Techniques for self-monitoring drug therapy.
• Proper storage.
• Prescription refill information.
• Action to be taken in the event of a missed dose.
http://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-
pharmacist/ArticleStandard/Article/detail/113520
http://en.wikipedia.org/wiki/Pharmacist
Pharmacists are health professionals who practice the science of pharmacy. In their traditional role,
pharmacists typically take a request for medicines from a prescribing health care provider in the
form of a medical prescription, evaluate the appropriateness of the prescription, dispense the
medication to the patient and counsel them on the proper use and adverse effects of that medication.
In this role pharmacists act as a learned intermediary between physicians and patients and thus
ensure the safe and effective use of medications. Pharmacists also participate in disease-state
management, where they optimize and monitor drug therapy or interpret medical laboratory results
– in collaboration with physicians and/or other health professionals. Advances into prescribing
medication and in providing public health advices and services are occurring in Britain as well as
the United States and Canada. Pharmacists have many areas of expertise and are a critical source of
medical knowledge in clinics, hospitals, medical laboratory and community pharmacies throughout
the world. Pharmacists also hold positions in the pharmaceutical industry as well as in
pharmaceutical education and research and development institutions.
In much of the United Kingdom and the British Commonwealth pharmacists are customarily
sometimes referred to as chemist (or dispensing chemists),[1] a usage which can, especially
without a context relating to the sale or supply of medicines, cause confusion with scientists in the
field of chemistry. This term is a historical one, since some pharmacists passed an examination in
Pharmaceutical Chemistry (PhC) set by the then Pharmaceutical Society of Great Britain in 1852
and these were known as "Pharmaceutical Chemists". This title is protected by the Medicines Act
1968 section 78.
The 1852 Pharmacy Act, June 30 established a Register of Pharmaceutical Chemists in Great
Britain , restricted to those who had taken the Society’s exams. However, the Act did not restrict the
practice of pharmacy to examined and registered people, nor provide a legal definition for the trade
and practice of pharmacy. This was first done by the Pharmacy Act of 1868.[2]
In the near future it is proposed by the Draft Pharmacy Order 2009 that the title "pharmacist" be
restricted to those who register with a new Regulatory body - the General Pharmaceutical Council -
due to be established to take this role over from the Royal Pharmaceutical Society of Great Britain
in 2010.
History
In ancient Japan, the men who fulfilled roles similar to those of modern pharmacists were respected.
The place of pharmacists in society was settled in the Taihō Code (701) and re-stated in the Yōrō
Code (718). Ranked positions in the pre-Heian Imperial court were established; and this
organizational structure remained largely intact until the Meiji Restoration (1868). In this highly
stable hierarchy, the pharmacists—and even pharmacist assistants—were assigned status superior to
all others in health-related fields such as physicians and acupuncturists. In the Imperial household,
the pharmacist was even ranked above the two personal physicians of the Emperor.[3]
http://www.who.int/mediacentre/news/new/2006/nw05/en/index.html
Rhttp://www.pharmabiz.com/article/detnews.asp?articleid=16088§ionid=46
Dr S B Bhise
The recently published 29th report of standing committee on Petroleum and Chemicals (2002)
under Ministry of Chemicals and Fertilizers (Department of Chemicals and Petrochemicals) has
once again sidelined the professional role of a pharmacist.
In the report, presented to Lok Sabha on November 25, 2002, the committee has recommended that
"The Govt. should explore the possibility of relaxing the provisions of The Drugs and Cosmetic
Act, 1940 so that educated persons other than pharmacists could sell the medicines after some short
training through "public distribution system" or "sarvapriya scheme".
According to the standing committee, the clause of employing pharmacists was more relevant when
the statutory acts were written in 1940 because the drugs were dispensed by the chemists by
compounding and mixing whereas now most of the medicine are available in ready to use form."
The committee further stated that "The pharmacist is the main hurdle in easy accessibility of
medicines and this move will provide better job opportunities to educated persons other than
pharmacists."
The learned members of the committee have probably not gone through the document `The Role of
the pharmacist in the health care system' published by World Health Organization (WHO). The
document is a report of a WHO consultative group meeting held in New Delhi during December 13-
16, 1988 and highlights professional role of pharmacists.
If the committee is of the option that 'mixing medicines' is the only job which a pharmacist is
supposed to do, then it can be argued that the learned members have incomplete comprehension of
the role of pharmacist in the healthcare system.
Over the years the professional role of pharmacists have evolved considerably. The WHO report
states "Effective medicine can be practiced only where there is efficient drug management." The
report further states, "Time and again, in less affluent settings, inadequacies in the provision of
primary health care are attributable to shortcomings within the drug distribution chain. Only when
the pharmacist has been accepted as a vital member of the healthcare team can the necessary
supporting services be organized with the professionalism that they demand."
The WHO report further clarifies that pharmacists are uniquely qualified because:
- They understand the principles of quality assurance as they are applied to medicines;
- They appreciate the intricacies of the distribution chain and the principles of efficient stock -
keeping and stock - turnover;
- They are familiar with the pricing structures applied to medicinal products obtained within the
markets in which they operate;
- They are the custodians of much technical information on the products available on their domestic
market;
- They are able to provide informed advice to patients with minor illnesses and often to those with
more chronic conditions who are on established maintenance therapy;
- They provide interface between the duties of prescribing and selling medicines and in so doing,
they dispose of any perceived or potential conflict of interest between these two functions.
In a diverse country like India, with more than 70,000 pharmaceutical formulations in the market,
maintenance of standards for quality of drugs is a stupendous task both for central and state
authorities related to drug-control. Preventing proliferation of adulterated, misbranded or counterfeit
drugs itself is an uphill task.
There is no doubt that distribution of drugs has to be eased out and drugs should be readily available
to the average consumers. However the best policy instrument to achieve the laudable objective is
to follow the policy of essential drugs as suggested by the World Health Organization (WHO) way
back in 1977. A large number of developing countries have followed the policy. The state of Delhi
has followed the policy of essential drugs; but with irrational policy and drugs being sold in other
states of India, an isolated state may not be able to make enough dents in the easy availability of
drugs to average consumers.
The right remedy for many ills in the distribution of the drugs is to scale down the number of drug-
formulations in Indian market to a minimum of say 1,000 instead of more than 70,000. Our country
certainly does not need such a huge number of formulations. More the number of formulations,
more is the administrative load over drug-control and more is the number of manpower needed to
monitor it.
In the post-liberation years, the size of government is reducing gradually and with the dictum of
"That government is best which governs least", availability of really needed minimum number of
drugs in Indian market will reduce the burden of government authorities over control of drugs.
It is irony of fate in our country that the ministry of chemicals and fertilizers rather than ministry of
health declare the drug policy. Probably there is a feeling in Central block that chemicals and
fertilizers rather than lifestyle are more intimately related to health.
The remark of the standing committee that "Pharmacist is the main hurdle in easy accessibility of
medicines" is certainly unfounded. With the kind of political, administrative and social structure in
our country, there is a lot to be done in distribution of drugs.
The WHO report on "The role of the pharmacist in the healthcare system" states that the
competence of the pharmacist is already proven and evident:
- In the direction and administrative of pharmaceutical services;
- In drug regulation and control;
- In the formulation and quality control of pharmaceutical products;
- In the inspection and assessment of drug manufacturing facilities;
- In the assurance of product quality through the distribution chain;
- In drug procurement agencies and
- In National and institutional formulary committees.
Unfortunately because of following factors, pharmacists have not been able to pursue their
international mandate in our country.
- Lack of understanding of the role of pharmacist in health care.
- Lack of identification of 'Health-care-team' as a policy concept and center-stage role only to
medical professionals in the maintenance of heath.
- More stress on curative measures rather than preventive measures for health related issues.
- Lack of national objectives of professional education being reflected in policy implementation.
- Peripheral role of pharmacist in health care only towards manufacture and distribution of drugs.
In developed countries like USA the role of pharmacist is next to the clergyman and he is looked as
the main source of correct information and availability of drugs. He is never a "hurdle", and in fact
will prove a boon in distribution of drugs.
Medication errors are a big issue even in developed countries like USA and pharmacist has a central
role in preventing medication errors and improving life expectancy of average consumers. It is
estimated that in USA, injuries caused by medical management are 2.9 to 3.7%. Preventable
adverse event is a leading cause of death in USA. When extrapolated to over 33.6 million
admissions to US hospitals in 1997, it was observed that between 44000 - 98000 Americans die in
hospitals each year as a result of medication errors. It is the eighth leading cause of death
comparable to deaths caused by motor vehicles (43458), breast cancer (42297) or AIDS (16516).
Medication errors can certainly be minimized with more and more involvement of pharmacists in
the administration of drugs.
There is enough evidence for the economic value of pharmacists in developed countries like USA.
A growing body of literature has emerged that supports the value of pharmacist's patient care
interventions in a wide range of patient groups, health care settings, and disease states.
- Over 20 studies and demonstration projects confirm that pharmacists add value to the health care
system by improving care and decreasing cost.
- During a six months period pharmacists joined doctors, residents and other members of the patient
care team on patients round in the intensive care unite at a large, urban teaching hospital. Result
showed that
- Preventable adverse drug events decreased by 66%
- A projected $ 270,000 related to adverse drug events could be saved annually
- 366 of the 400 pharmacist interventions were related to medication errors.
- Pharmacist interventions helped prevent incomplete orders, incorrect dosages and frequency, less-
than - optimal drug choices, and duplicate prescriptions.
- Pharmacists working in their communities produced a 74% increase in vaccination rate by
advising high-risk patients of infection risk and describing where to go to be vaccinated.
- Patient acceptance was excellent, with pharmacists administering 1060 doses of influenza
vaccinations and 198 pneumococcal vaccinations to 1067 patients.
- Pharmacist reviewed drug therapy and found ways to improve medications used in nearly 65% of
all patients.
- The bulk of savings were not related to drug costs, rather they were associated with fewer
unscheduled physician visits and fewer hospital days.
- Consultant pharmacist-conducted drug regimen review increases the number of patients who
experience optimal therapeutic outcomes by 43% and saves as much at $ 3.6 billions annually in
costs associated with medication - related problems.
- Pharmacists working with patients in their community provided targeted patient education,
systematic patient monitoring, patient feedback and behavior modification.
- Savings for monthly medical cost ranged from $ 143.96 to $ 293.39 per patient per month.
The result of these studies suggest that a broad range of hospital-based pharmacist-provided patient
care activities either save lives or reduce health care costs or both. In a study evaluating the effect of
clinical pharmacists on the economic outcomes of patient care an average benefit of $ 16.70 of
value to the health care system was realized for each $ 1 invested in clinical pharmacy service. Drug
therapy changes based on pharmacists' recommendation reduced unscheduled hospital visits, urgent
care visits, emergency room visits and hospital days, saving over $ 640 per year in health cost per
individual ($ 280,000 per year per pharmacist).
In order to have such an important role for pharmacist in Indian health care, objective based
education oriented towards the purpose needs to be implemented.
In a multifaceted country like India, what happens in politics is reflected in all walks of life.
Division amongst people is advantageous to certain sections of society. The same policy is being
unfortunately implemented in the health profession. Physicians, pharmacists, nurses and other
health-related professionals should work in harmony towards the central benefit of "PATIENTS".
Patients, rather than any professionals should be at the center-stage of health policy and
professionals should not quarrel amongst themselves for their central or peripheral role in the well
being of patients.
It is the lack of this understanding on part of honorable members of the standing committee that has
lead to the belief that "Pharmacist is the main hurdle in easy accessibility of medicines". World over
pharmacist is one of the important member of the health-team including clinical research. If Indian
pharmacist is not fulfilling this role, then he should be appropriately trained and be oriented as a
health - care provider to the vast rural population. He can be used intelligently as an alternative
manpower towards the sacred goals of:
- Immunization
- Minor dressings
- Family planning
- Preventing tropical diseases
- Providing drug-information
- Monitoring adverse drug reactions
- Monitoring and minimizing adverse drug interactions
- Preventing misuse of drugs
- Preventing medication errors
- Preventing abuse of tobacco, alcohol
Much of the role of preventive and social medicine can be attributed to pharmacists. In fact
pharmacists can be real 'bare-foot' doctors to average consumers of rural India. What we need is the
vision of policy-makers rather than marginalizing role of any professional in the health-care team.
Pharmacist is certainly not a "Hurdle but can be a boon and facilitator in the process of efficient
drug - distribution.
http://www.shepscenter.unc.edu/rural/pubs/finding_brief/FB88.pdf
A Joint Publication of The North Carolina Rural Health Research & Policy Analysis Center (1)
and The RUPRI Center for Rural Health Policy Analysis (2)
The Key Role of Sole Community Pharmacists in
Their Local Healthcare Delivery Systems
Andrea Radford, Dr.P.H.(1), Indira Richardson, M.P.A.(1), Michelle Mason, M.A.(2), Stephen Rutledge
(1)
OVERVIEW
Sole community independent pharmacists provide essential services to residents of small towns and
isolated communities. Anecdotal reports indicate their role within the local health care community
is
often multi-faceted, extending beyond the provision of prescription and nonprescription medications
at
their retail stores. In 2008, we surveyed 401 community pharmacists that are the only retail provider
in
their community to document their extended relationships with other health care providers and the
additional health care services these pharmacists provide to their patients. Pharmacist-owners in
independent pharmacies located at least 10 miles from the next closest retail pharmacy were
interviewed
to determine the presence in their community of other types of health care organizations that require
pharmaceutical support i (such as hospitals, long-term care facilities, hospice providers, home health
agencies and community health centers), their level of involvement with those facilities, and the
types of
clinical services (other than dispensing and counseling) the pharmacists offered to their own
patients.
KEY FINDINGS
• Most sole community pharmacists (83%) provided important services for other
health care providers and facilities in their communities.
• Almost all (92%) of the communities served by a single independent retail pharmacy are
also served by at least one other type of inpatient or outpatient health care organization.
• Skilled nursing or long-term care facilities, hospice providers and home health agencies,
all of whom serve predominately elderly patients, were the most common types of health
care organizations in the communities surveyed.
• Almost half of all pharmacists (42%) offered additional clinical and educational services
to community residents including blood pressure checks, screening for cholesterol and
osteoporosis, glucose screening and diabetes counseling, tobacco cessation programs, and
immunizations.
i Private physician practices were not in included in this study, as they typically do not provide the type of services that
require on-site pharmacy support.
Findings Brief March 2009
2
PRESENCE OF OTHER COMMUNITY HEALTH CARE ORGANIZATIONS
Almost all (92%) of the sole community pharmacists interviewed reported the presence of one or
more
different types of health care organizations in their community. The most commonly reported were
skilled nursing or long-term care facilities (66%), hospice providers (62%) and home health
agencies
(54%). Fewer communities were served by a local hospital (32%) and community health centers
(29%).
The most common types of other health care providers located in these communities – skilled
nursing/
long-term care, hospice, home health agencies – are organizations whose patients are predominately
elderly. While hospitals were reported less frequently in these communities they also provide
critical
services to the rural elderly. Given the higher use of pharmaceuticals by older patients, the
availability
of local pharmacy support is critical for health care providers who serve elderly patients.
PHARMACISTS’ INVOLVEMENT WITH OTHER COMMUNITY HEALTH CARE
ORGANIZATIONS
The majority of pharmacists (83%) reported working with one or more of the other health care
organizations
in their community. They provided services most frequently to hospice providers (94%), to skilled
nursing or long-term care facilities (79%) and to home health agencies (74%). Services were
provided
less frequently to local hospitals and community health centers (Figure 1).
Figure 1. Provision of Services to Other Health Care Organizations by Sole Community
Pharmacies (when other health care organizations are present in the community)
SERVICES PROVIDED TO OTHER COMMUNITY HEALTH CARE ORGANIZATIONS
Pharmacists were asked about what types of services they provided to other health care
organizations in
their communities. Not unexpectedly, providing medications was the most common service
provided,
ranging from 96% who reported providing medications for hospice patients to 69% who provided
dispensing
services at their local hospital. Some of the other types of services pharmacists reported
providing to the different types of health care organizations present in their communities included
the
following:
HOSPICE:
• delivery of medications (58%)
• on-call services (54%)
• compounding (39%)
SKILLED NURSING FACILITIES/LONG TERM CARE:
• fi lling medication cassettes/unit dose dispensing (87%)
• monthly chart reviews (35%)
HOME HEALTH:
• delivery of medications (60%)
• provision of durable medical equipment (40%)
HOSPITALS:
• pharmaceutical inventories (57%)
• billing for medications (24%)
• rounding on hospital patients (12%)
COMMUNITY HEALTH CENTERS:
• dispensing 340B medications (46%)
• counseling diabetic patients (30%).
ADDITIONAL SERVICES PROVIDED TO THEIR OWN PATIENTS
Pharmacists were also asked whether they provided additional clinical services other than
dispensing
medications and counseling to their own patients. Of the pharmacists surveyed, 42% stated they
offered
one or more additional clinical services. The most common services provided were blood pressure
checks (12.9%), diabetes counseling and blood glucose testing (12.4%), immunizations (9.7%) and
providing
educational classes or participating in health fairs (8.2%). Other less commonly reported services
included offering tobacco cessation programs and providing screening tests for osteoporosis,
asthma,
hearing, and cholesterol. Medication delivery for their own patients and as a service to other
community
health care organizations was also frequently reported by these sole community pharmacy
providers.
DISCUSSION
For purposes of this study sole community pharmacies were defi ned as independent retail
pharmacies
located 10 or more miles from the next closest pharmacy. Despite the distance from other retail
pharmacy options, most of the communities in which sole community pharmacists provide
pharmacy
services have other health care facilities that require pharmaceutical support, ranging from inpatient
care providers such as long-term care facilities and hospitals to outpatient providers such as home
health
agencies and community health centers. All of these health care providers need supportive
pharmacy
services to function, the most basic being access to medications needed by their patients. Sole
community
pharmacies provide this support and more to these partner agencies and help ensure access to
important health care services for residents of their community.
Sole community pharmacists also provide health monitoring and preventive care services such as
blood
pressure or glucose screening and immunizations for local residents. These important monitoring
functions are particularly valuable in areas where primary care providers are less common and
residents
may otherwise have to travel long distances for simple screening procedures.
The fi ndings from this study document the important role sole community pharmacists play in their
local
health care delivery systems, and supports the notion that the survival of sole community
pharmacies not
only ensures retail access to pharmaceuticals and patient counseling but also, in many cases, access
to
other important health care services that are particularly needed in communities with limited health
care
options.
4
This study was funded under a cooperative agreement with the Federal Offi ce of Rural Health Policy
(ORHP),
Health Resources and Services Administration, U.S. Department of Health and Human Services,
Grant Number U1GRH07633. The conclusions and opinions expressed in this paper are the
authors’ alone; no endorsement by the University of North Carolina, the University of Nebraska, ORHP,
or other sources of information is intended or should be inferred.
STUDY METHODS
A semi-structured interview protocol was used in this study. To be included in the survey,
pharmacies
had to be independently owned and located 10 miles or more from the next closest pharmacy. A
subset
of pharmacies likely to meet these criteria were identifi ed using data from the National Council for
Prescription Drug Programs, Inc., which contains information about the 74,108 pharmacies in the
U.S.
with active provider numbers. Pharmacies with the following characteristics were identifi ed:
independently
owned (including franchise licenses); operating as a community retail pharmacy; the only
pharmacy within its ZIP code; and the only pharmacy within a ten mile or more Euclidian buffer
from
the next closest pharmacy. Application of these criteria resulted in a fi nal sample of 1,148
pharmacies.
The pharmacy’s eligibility to participate in this study was verifi ed during the initial telephone
contact.
The study goal was to complete 400 interviews. Attempts were made to contact the owners of all the
pharmacies in the sample. No contact was made with 5 pharmacies (no answer or busy signal), for
151
pharmacies the pharmacist-owner was never reached in ten or more attempts, 43 stores were confi
rmed
closed, and 68 did not meet the study criteria. Of the remaining 881 pharmacies, 401 participated
for a
response rate of 46%.
ADDITIONAL NCRHR & PAC AND RUPRI PUBLICATIONS ON INDEPENDENT
PHARMACIES AND MEDICARE PART D
Available at: http://www.shepscenter.unc.edu/research_programs/rural_program/index.html
Findings Brief No 87. Sole Community Pharmacies and Part D Participation: Implications for Rural
Residents. (2009).
Findings Brief No. 83. One Year In: Sole Community Rural Independent Pharmacies and Medicare
Part
D. (2007).
Final Report No 92. One Year In: Sole Community Rural Independent Pharmacies and Medicare
Part D.
(2007).
Final Report No 87. The Experience of Sole Community Rural Independent Pharmacies with
Medicare
Part D: Reports from the Field. (2006).
Available at: http://www.unmc.edu/ruprihealth/
Brief No. 2009-2. Rural Enrollment in Medicare Part D is Growing Slowly. (2009).
Brief No. 2008-5. Eligible But Not Enrolled? Potential for Targeting Over a Half-Million Rural
Medicare
Benefi ciaries for Enrollment in the Low-Income Subsidy Prescription Drug Program. (2008).
Brief 2008-2. Independently Owned Pharmacy Closures in Rural America. (2008).
The authors wish to acknowledge the valuable assistance of the RUPRI staff
in preparing the sample of pharmacies and conducting interviews.