Y’know, I am in beautiful but snowy Corner Brook, Newfoundland where my younger daughter is curling at the Canadian Junior National Championships. It is a week-long event, and just as we arrived here the CBC Marketplace report about pharmacy errors was airing.We had to watch it online to catch up with what the rest of you probably already knew for a day or more. After taking it all in, I had to write this blog. It’s kinda long, but this is a pretty big deal.I don’t think there is a practising pharmacist in Canada who didn’t feel a twist in their gut when they saw this. I also don’t think that any pharmacist believes the problem is as big as CBC says it is. In our world of pharmacy, the problems are many times bigger.Drug interactions are a significant health risk and all too often go unidentified. There is no argument there. The problems are that there will be a debate about who’s fault this is, and having that argument and the subsequent fallout will diminish or hide the much larger problem that is out there. The bigger issue is that pharmacists are not used in the best interests of the health of their patients.So let’s start with the blame. The pharmacists commenting on camera largely had it right—the environment that pharmacists practise in is not conducive to providing the best care for patients.Good on CPhA’s Jane Farnham for having the guts to do an interview. I know it must’ve been tremendously difficult as she tried to defend her profession in an unwinnable debate. And shame on the Neighbourhood Pharmacy whatever—changing the name didn’t change the face, and they clearly realized they could not dismiss or refute the CBC report, so they turtled (for those who aren’t familiar with the vernacular, the name sums it up).Then they issued a nonsense press release saying patient safety is important. Is there really any possibility to say the contrary?So let us not quibble about the quotas and the metrics, and the cuts to technicians and pharmacist overlap. Everyone knows it has been happening more and more, and everyone knows that it means pharmacists have less time to spend on drug therapy problems. Let me say it again. Pharmacists have less time to spend on drug therapy problems. I thought that spending time on drug therapy problems is why we are here in the first place.Beyond drug interactionsThis brings us to the larger point. Drug interactions are only the tip of the iceberg. If you look at the pharmaceutical care process, this is just one check of many.Pharmacists use this process to not only check that the therapies the patient has are the right ones (and not just the right ones matching what it says on the label and which should match what was originally prescribed), but that the patient is getting the best possible benefit from their therapy.How many patients have a condition that should be treated but isn’t? How often as a pharmacist have you discovered that? Imagine what you would find if you were systematically checking for your patients–if you had the time and resources.How many patients take a therapy that has no indication? How often do we come across a patient’s description of self-treatment and sometimes even prescribed treatment that has no merit or benefit? What if you pro-actively sought this out with every patient?Have you ever seen a dose that seemed off, a little or even a lot? How about an iffy or outright wrong indication? Or maybe the indication is OK, but that was a standard of practice in the eighties and things have changed. Is the therapy working? Is it working well, or just OK?And beyond drug interactions, is the therapy playing nice with other conditions the patient may have? Does the regimen even work with how they live their life? We see it all the time. You would not believe how much more you would see if you were actively looking for it systematically for every patient all the time.These are some of the components of the pharmaceutical care process. I look for these things in my practice. I do it for patients who have a pharmacist or sometimes more than one, several doctors, other providers and other services. I usually find between 15 and 25 drug therapy problems in each patient assessment.I am probably not finding them all, but I do find a lot that no one else has. And it isn’t because their pharmacist is doing a poor job. It is because they are not doing the job that pharmacists are uniquely qualified to do. That goes past the work environment to the bigger problems of a health system that does not engage in the above to the extent the public needs.Fixing non-adherenceAnd there is more. What about adherence? It is nowhere close to where it should be, as we pharmacists occasionally trumpet. Yet, who’s fault is it that adherence is so terrible, if not ours? It has been our province for years.Does every patient who doesn’t pick up refills on time get consulted as to the reasons why? And for those we slap on adherence packaging, who checks that they take it as the packaging suggests? After all, we know that 80% of non-adherence is wilful, not accidental. Non-adherence to therapy kills way more people than all of the rest of the drug therapy problems combined.If anyone asks for the evidence, it is really quite simple. Probably the best way of explaining benefit vs. risk is the number needed to treat vs. the number needed to harm. The first number is almost always way smaller than the second. That is the reason it is worth treating patients with pharmacotherapy.How does non-adherence to therapy fit in? It means that the number needed to treat to benefit from therapy (e.g., treating 10 patients to prevent 1 heart attack) requires that the medication be taken. If the patient would benefit but does not take the medication, than the number needed to harm is exactly the same.For 10 patients who would benefit from preventative therapy that do not take their treatment, the number of non-adherent patients needed to harm would be one heart attack for every 10 not adhering. The numbers become staggering when we talk of hundreds of thousands of non-adherent patients.And then we have minor ailments and injections. We should also be adjusting doses to target, and within a year pharmacists will have online access to lab results from OLIS across the province.That means you will be able to see how the thyroid or cholesterol or other therapies are working, how the electrolytes and blood counts are shaping up and how the A1c or kidney or liver function is.Then you can take the last two to assess whether there are drug therapy problems related to dosing or suitability. The first ones not only help ascertain targets, but the dialogue with the patient about the targets helps improve adherence.As far as fixing adherence goes, it can be done. It won’t be perfect, but using motivational interviewing and health coaching and patient education can make a huge dent. No one is better positioned than pharmacists to take on that role.And then we get to tackle the health beliefs and subsequent health behaviours of the public who trusts us to look out for their better interests. There are very few places in health where these issues intersect with outcomes to the degree they do with using and choosing medications. Our patients need our facility with education, motivational interviewing and health coaching.Yes, the problem is so much bigger, as is the potential of pharmacists. And that is why there are so many coming out of school. If we did all of these things, and did them well, there is more than enough work to go around. And that is what these kids are being trained for, not to provide a cheaper and easily bullied labour pool.A simple solutionBut of course, never pose a problem without a solution. Otherwise, you are just whining. We won’t see any owners of pharmacy, who only seek higher profits and margins, leading the profession. There has also been a leadership gap from our associations. They may take the chain out of the name, but they will always see pharmacists as someone to be chained to a counter churning out profits.It will be pharmacists who will break the chain by standing up for themselves, for their profession, for the public and for doing the right thing. Health care is different than any other industry. Those who suggest it isn’t simply do not understand it or value health the way our patients and public do. Quite frankly, those people would be doing us all a favour by getting out of pharmacy. None of us would want health professionals constrained from giving us their best. Nor should we accept a world where that can happen.The solution is quite simple, and I have proposed it before. Give each patient their due, whatever they need. Do not choose patients that are easier and faster over the more complicated. Treat them as equally important.Remind those who would place measures on you that the value is not the prescription filled, but the knowledge behind ensuring it is the right one (and all that that means) and also the skill and dedication in ensuring that it provides the outcome you wanted in the first place. That is our place, and we have only scratched the surface of our potential.Let your metrics be the ones that count. A life saved, suffering averted, accidents prevented, quality of life improved—those are the metrics we pharmacists should be measured by. Don’t let anyone tell you otherwise.Ken Burns is a pharmacist at the Diabetes Care Centre at Sudbury Regional Hospital.
