Collaboration between family physicians and community pharmacists

DISCUSSION

The goal of the survey was to explore the perceptions of graduates in family medicine regarding collaboration between family physicians and community pharmacists. Overall, our results indicate that graduates are open to collaborating actively with community pharmacists. These results are very positive, especially as collaborative practices are in their infancy. Such collaboration is of varying complexity; examples include writing important clinical data (eg, creatinine levels) on prescriptions in order to make it easier to adjust medications, and agreeing to share several professional responsibilities traditionally reserved for family physicians (eg, adjustment of anticoagulant therapy or initiation of treatment of traveler’s diarrhea) that follow from collective prescriptions. This finding is encouraging because increasingly more training initiatives are being implemented in health sciences programs—including family medicine—to make future professionals aware of the importance of collaborative practice and of learning about it.

However, some studies show that although the perception of collaboration with community pharmacists is promising, such collaboration requires “arrangements” of roles and responsibilities between the 2 professions, and this poses a number of challenges.^20–25 For instance, our results show that supervisors do not seem to value including therapeutic intent on prescriptions (Table 2), even though this information is often useful or even necessary for pharmacists to intervene effectively.²⁴ Working collaboratively requires communicating to pharmacists the information they need to do their jobs appropriately.²⁵ How will future doctors develop this habit if their preceptors do not value it? This aspect is important because learning from supervisors, whom students see as their role models, plays a determining role in developing residents’ professional skills.²⁶

An analysis of the frequency of and the reasons for consulting community pharmacists revealed that graduates did so infrequently, and usually for “traditional” reasons (eg, obtaining the list of a patient’s medications); consulting pharmacists for their pharmacologic expertise, such as to ask for a professional opinion, was less common. Perhaps residents did not have to consult pharmacists more often because they had access to electronic tools that answered their questions on medications. Unfortunately, we did not have the number of times and frequency with which accessed residents electronic tools. Our results can also be explained by the fact that graduates had access to hospital pharmacists who were members of their team. Another explanation might be graduates’ lack of knowledge of pharmacists’ professional expertise in management of chronically ill patients: graduates are more likely to be aware of the drug management role of community pharmacists and less likely to see pharmacists’ contributions as complementing the physician’s role (eg, providing lifestyle habit counseling and pharmaceutical care to patients). However, regarding the question about who should ensure that a patient is given the information required to manage his or her disease (Table 5), the fact that around 50% of graduates consider this responsibility to be mostly the physician’s does not necessarily mean they are not aware of the pharmacist’s role: graduates might have interpreted “disease management” as medical management of a health problem. With regard to the question about pharmacists prescribing drugs for pain management according to protocols based on therapeutic guidelines, we do not know how respondents interpreted this question: prescribing anti-inflammatories is one thing; prescribing narcotics is another matter.

When analyzing results related to adjusting or initiating treatments as per a collective prescription, opinions were much more divided. Such a plurality of viewpoints illustrates that the roles and responsibilities inherent in collaborative practice require continual adjustments, which do not necessarily go smoothly. Beyond corporatist issues, it remains that sharing professional responsibilities largely rests on the nature of the clinical situation. For instance, it is easier to initiate treatment of a problem like traveler’s diarrhea or juvenile acne because neither necessarily requires clinical examination. However, medical or laboratory examination is needed for cystitis and pharyngitis. (Hormonal contraception is an exception, as in Quebec nurses can now prescribe it.) Therefore, the results are not surprising.

Furthermore, we can question whether the multiple opinions of graduates are also linked to an unfamiliarity with the meaning of collective prescription. Overall, graduates’ opinions about shared responsibility conform to those expressed by general practitioners and specialists in a recent survey on the responsibilities of pharmacists carried out by the Association Médicale du Québec.²⁷ Overall, respondents indicated that they somewhat agreed with the fact that community pharmacists adapt, extend, or initiate treatment based on preestablished conditions in order to contribute to solving certain simple health problems.

The field of interprofessional collaboration is shifting. In Quebec, the public stands taken recently by professional orders and legislative action undertaken by the provincial government (Bill 41) will result in changes in the roles of pharmacists and physicians and how these roles are shared in collaborative practice. In the near future, collaboration will not only be a question of perception but also of integration into the clinical practices of future physicians.