FELLOW professionals often say to me that it is the pharmacist who is the expert in drugs and their delivery.
The absorption, distribution, metabolism and excretion of drugs is our primary focus when caring for patients. We will take a holistic view of how the chemistry of compounds may have positive or negative effects on the patient. I take pride in trying to learn as much about the pharmacokinetic and pharmacodynamic aspects of a particular drug so that I maintain that point of difference from colleagues in the rest of the multidisciplinary team. The ultimate goal here is to keep the patient safe, and make sure the drug has the desired effect.
At its most crude we could consider community pharmacists as legitimate drug dealers. I should know, I am one myself. These pharmacists dearly want the medicines they sell to have the desired effect with little or no side effects so that the customers return for further purchases or tell their friends how wonderous the particular remedy was (even though in actual fact they may simply be observing/describing the natural course of a self-limiting disease).
I have always thought that this rather simplistic commercial model has ironically been a core aspect to the evolution of the ‘chemist’s’ trusted reputation. The need to capture the business in a given neighbourhood or high street has driven pharmacists to come up with ever more imaginative concoctions for whatever ailment walks through the door.
The thought being that pharmacists will immediately supply something useful to ease the ailment and difficult evidence-based decisions are sometimes glossed over in favour of making the sale to a loyal customer. The long term management of the patient’s conditions cannot properly be considered at the till without access to patient records.
You will notice that in the commercial model I refer to the customer, and not the patient. This approach I believe does come at the price of a certain amount of credibility, although I admit this is fantastically difficult to measure. Never has the credibility of healthcare professionals been under as much scrutiny as it is today.
Perhaps there is room for some non-evidence based treatment, as long as we can professionally justify our decisions.
Is it ethically right, for example, to sell a cough bottle that you know will probably not do much good, if the result is a saved GP appointment?
Perhaps, if it’s late in the day you might even prevent the prescribing of an unnecessary antibiotic.
You might notice a patient repeatedly buying cough remedies over the counter and refer them to their GP. If the cough has been around for more than six weeks the patient might need a chest x-Ray or other further investigations.
An asthmatic patient repeatedly buying cough bottles may need their inhaler therapy tweaked, or their inhaler technique checked to regain control.
Ironically the trust is built based on the fact that we sell a ‘solution’ to their problem. The ‘further investigations required’ elephant in the room is perhaps an evidence based tack to take but it holds no weight in the reputation with the clinically naive patient.
My own view, is that as pharmacists we should put the patient at the centre of everything we do. The days of paternal care models are all but gone. Is it not up to us to sift the evidence of the products we sell or prescribe, and inform the patients properly so that the patient can make sound decisions about their own care?
My view is that honesty is the best policy, and therefore practicing evidence-based medicine directed by consensus guidelines is the best way to go. Best for patients that is.
The profession has already made a stand against homeopathy due to a lack of evidence of efficacy. Try going on Twitter and tweeting ‘I love homeopathy’ in pharmacy circles and the social media masses will mobilise and the echo chamber will begin to resonate with cries of general disdain. However as I gaze at the pharmacy back wall it is clear that the evidence underpinning many of these preparations is no-where near sound.
Perhaps it’s time to consider the overall evidence based benefit vs potential harms of the remainder of the over the counter remedies.
Why stop at homeopathy? I recognise that that this could be painful commercially in the short term, but will serve our patients and our profession better in the long run.
Pharmacy is a profession built on a core of evidence gathering and assimilating. Decisions we take need to be in line with the most up to date comprehensive evidence available in any given area. If we fail to apply these principles with rigour then as a profession what are we for?
Johnathan Laird is a community pharmacist, GP practice pharmacist and independent prescriber with a special interest in asthma.
Follow Johnathan @JohnathanLaird