Getting prescribing teams right

Times are tough for those who care for patients. When times are tough, words can get rough, even between two professions that work closely together. The current primary care landscape has led to barbs that have the potential to harm the pharmacist-physician relationship, a partnership that’s essential to patient safety and care.The Medical Post’s Kylie Taggart listened in on a conversation about physician-pharmacist collaboration between Dr. Taylor Ferrier, a family physician and medical director of Tay River Health Centre in Perth, Ont., and Kristen Watt, a pharmacist and independent pharmacy owner in Southampton, Ont.Their discussion touched on the Ontario Medical Association (OMA)’s pushback on the province’s plan to further expand pharmacists’ scope of practice, medication reviews, the need for appropriate remuneration, access to patient records and other topics.It started with examples of what’s working in the pharmacist-physician relationship.Patient safety and the pharmacist-physician collaborationDr. Taylor Ferrier: Patients are often receiving care not just from their primary-care provider, but from numerous specialists. Their disease burden and the complexity of their care can overlap, and so can their medications. Sometimes those medications may be cancelled by another provider or maybe another medication may be added on and the primary care doctor isn’t aware of it. The patient follows up with me and I may start them on a similar medication. Then the pharmacist will chime in, almost within the next couple of hours, saying, “They’re actually on this medication,” or, “This was already stopped.”Pharmacists provide a wealth of stop-gap measures that otherwise we’re not necessarily privy to for a variety of reasons, like the shortcomings of our EMRs and our interconnectedness. I’d need everybody’s fingers and toes in my clinic to count how many times pharmacists come in to bring attention to really important matters like that. There’s a collaboration on patient safety that’s exceptional, that’s often forgotten during times of stress and strain on the healthcare system.Kristen Watt: I don’t think the relationships that happen on Twitter or through the OMA are necessarily reflective of what happens in real life. Having said that, the results of those things are felt on the ground. We get pushback and hear things from physicians that mirror the OMA speaking points and what we see on Twitter, and that’s where the relationships really start to fracture. It’s never a pharmacist’s intention to come between the relationship between a patient and their family physician but to be part of the circle of care.I always say that patient care is not a pyramid, with the family physician or any practitioner on top: It’s a circle with the patient in the middle and we’re all honoured to be part of that care.I think a big shift and movement that I’ve seen in pharmacy providing care is not just in safety and stop-gap, but more in proactive approaches in care; therapeutic optimization and patient-outcome focus. That’s truly what we’re trained to do. What I do in my practice, in my community, is longitudinal care collaboration with a family physician. For example, I’ll get patients in with diabetes and I’m asked to optimize their A1C. Another thing we do in our region is pain management.Providing proactive care without appropriate remunerationWatt: It’s really challenging when what we do is not compensated—both us and family physicians. I think that’s where we really run into the stress in the relationship. If we make a recommendation and fax it over to family medicine, they’re not necessarily paid to open the chart and sign off on the script, but they just provided patient care.I don’t think that the ire we receive is directed at us, per se, or should be, but it is felt by all of us, because so much of the care we provide is not covered, and so much of the care family medicine provides is not covered. That’s where it can get really taxing on everybody.We all need to look to the funding source together to demand ongoing improvements in patient care and access through funding. I think that’s where we’re really going to see the best collaboration come out. It’s already happening on the ground, but on the flip side, we have pushback in a number of areas, being told that’s not in your scope, that’s not something that you should be doing when it is—it’s something that we’re trained to do and it is something that we should be doing and we do have now the statutory obligations to provide that level of care to patients. It’s just the communication piece adds an extra burden to family physicians so it can be so burdensome to everybody in the circle of care.Dr. Ferrier: I can appreciate that you get a variety of different physicians feeling different types of stressors and that ultimately ends up on your doorstep. I think where we agree is that a collaborative and constructive approach to primary care is absolutely essential. I think it’s the structure itself that a lot of doctors struggle with. For example, if a family health team had a pharmacist as part of the team, the pharmacist would have access to the entirety of the patient’s chart. It’s a true collaborative approach where there’s strong communication that exists between the pharmacist and the patient and I think we’re removing a lot of the paperwork aspect.I would even go on to say that the minor ailments program is such a small step forward in general. I would say that we need pharmacists to be more involved with complex patients. Again, it’s the funding piece that sells everybody short here. It’s a tough piece.Watt: It’s been an uphill battle. If you look at the wording from the OMA just about minor ailments, it’s concerning. The questioning of the quality of care—I mean, this is stuff we do in the aisles. Diaper dermatitis is stuff we do in the aisles.Expanding pharmacists’ scope of practiceDr. Ferrier: We have a very stressed-out primary-care health system right now. Having more healthcare professionals with the competency to provide the care is absolutely imperative. We need it. There’s a caveat to that, which is we have an OMA body, and we have a pharmacist body and what I’m hearing right now, is there’s not a lot of collaboration. The third piece is the ministry. And there’s the patient in the middle. How can we work together to provide this?The problem that I see on the physician’s front (with pharmacists’ expanding scope) is that we’re not really good at delegating tasks. Oftentimes we do see ourselves at the centre of a patient’s care, and often we are, but we do have to recognize that there are other healthcare providers who are in just as good a position to provide that care for those minor ailments.I think pharmacists’ roles should be further up in terms of the complexity tree. I’ve seen it already with my training. I’ve seen it before in the clinic where we’ve had pharmacists working with us side-by-side in the clinic, working on chronic pain. I’ve seen numerous examples where it’s gone exceptionally well.MedsChecksNote: MedsCheck is a program in Ontario where pharmacists can do a one-on-one medication review with a patient. A report is sent to the family physician and the province is billed.Dr. Ferrier: I think it’s a brilliant idea. I think, to be fair, both parties are already doing med checks. Whenever a patient comes in, I’m reviewing their complete medication history, their indications for the medication, their dosing. I think some of the friction is we don’t get paid for that. The pharmacy team is also doing that every day they encounter a patient anyway, and now they’re getting paid for it.I don’t want to get into the politics of certain pharmacies overwhelming the patients and their providers with less-than-indicated MedsChecks. When I work with the pharmacy team that’s closely related to our health centre, they’re hitting the mark almost each and every time (on sending appropriate MedsChecks).Watt: The corporate pressure piece (to do MedsCheck) is really concerning and we absolutely condemn it.For all that we do, we always go back to: What’s the reason for care? For me, there are four reasons to provide a MedsCheck.A patient asks—they want a better understanding; I’m happy to provide that care.A physician asks—I get sent a request to do a medication recommendation or review their renal meds or whatever; I’m going to do it.I identify an issue—because of their A1C or they’ve got four providers and now I’m collating all of this.There’s a transition of care—I do one after every single hospital discharge in addition to reviewing the discharge summary. I also send it off to their family physician because things get missed. A MedsCheck should never be performed just because they’re on meds.Dr. Ferrier: We’re in agreement on that. Just to let you know, when it first started, we were getting five, maybe six a month per doc. One time I got 300.Paperwork burden and its repercussions for physician-pharmacist relationshipsDr. Ferrier: People assume the paperwork burden is around the insurance forms, the tax disability forms, the work sick note forms—those are not the forms or paperwork that we’re worried about. For example, we get hundreds of lab results, consult reports, med renewals—we’re talking about paperwork that we’re not directly involved with. I don’t want to say that we’re a dumping ground, because we need the information, but we just don’t have the funding to put the appropriate person in place to coalesce that information and put it into the chart. It leaves the physician as a basic office administrator of paperwork. What that does is it pulls us away from the patient.When you have something with the good integrity of a MedsCheck and the minor ailments program but there are a few bad apples, you’re asking us to find a needle in the haystack of needles to find the ones that are meaningful and appropriate.When resources are strapped, and people are pushed to their limit, burnout is happening, often instead of banding together on how we can improve our system, infighting ensues. Because they can’t get the traction they need from the ministry.There’s nothing good that comes out of bickering back and forth between a physician and a pharmacist. It’s wasted energy and we’ve quickly recognized here that this is a good relationship.Watt: If we look back, 30 years ago, 50 years ago, the level of patient care we provided—both you and me—is so different. Our patient acuity is so vastly different. And funding didn’t keep up with that. It’s still attached to, necessarily, the patient as a whole, but not necessarily all the interactions and interventions. If we really get back to being patient-focused, then you can go back to a family practice that is properly compensated to do all these things with the right amount of patients that you can actually provide this level of care for—because we can’t anymore. It’s just wild.Dr. Ferrier: My predecessor had 2,000 patients.Watt: How do you provide that care?Dr. Ferrier: That was 10 to 20 years ago. They were also doing emergency, inpatient care. They were able to balance it because the age of the patient was 40 to 50, a lot of younger people. Now, the average doctor has 800 to 1,200 patients, so that’s put a huge downward pressure in terms of income coming into that practice. This is combined with inflation driving costs upward and it’s squeezing the financial viability out of family practice.Physicians are asking: “Where are we going to get this funding from?” You have these goodwill gestures like getting better and more appropriate providers in the right place, like pharmacists, but it’s patchwork to a system that really needs a true overhaul and it can’t be as a physician as a sole provider.Appropriate funding for patient-centred careWatt: The care that we both provide in our settings is the best care that we can provide in that moment. Everybody is trying to do what’s right by the patient. We all have to remember that in those frustrating moments when we have hundreds of faxes, or there’s another cut to pharmacy or someone bites back, that it’s probably not about me, or you, or anybody else, it’s about the frustration in that moment—but the care needs to continue to be about the patient.Dr. Ferrier: It is always about the patient. It’s very hard to be in a financial situation that actually compromises patient care because we are underfunded, but in the same breath, we also have to say it’s for the good of the patient. That can’t continue anymore. The pressures are such that if it is about the patient, then the appropriate funding needs to ensue.I hope to see better collaboration and an elevation in the complexity of care that pharmacists provide. And if they are to provide it, we need a communication format that actually connects us in a way that’s appropriate for the care of the patient.

Getting prescribing teams right

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