How "Scope Creep" Can Save Health Care
In its ongoing campaign against “scope creep,” the American Medical Association argued that pharmacists don’t receive enough training. Physicians and pharmacists alike disagree.
In early February, an article published by the American Medical Association (AMA) began making the rounds on social media. In it, the author makes sweeping claims about the role of the pharmacist in the health care setting, framing them as lesser than physicians in their training and expertise.
Interprofessional health care team / laddawan - stock.adobe.com
“While pharmacists play a vital role in the health care team, the best way to support high-quality care is to keep physicians as the leaders,” wrote article author Timothy M. Smith, on behalf of the AMA.1 Although the article begins by acknowledging the value of pharmacists in a collaborative setting, it quickly doubles back, suggesting the importance of a hierarchy rather than true collaboration.
The author of the piece is quick to point out that physicians receive more than 6 times the clinical training as pharmacists receive, making them the “leader” in health care, which the article asserts matters much more than convenience. The lack of training that pharmacists receive, the article continues, illuminates the danger of test-and-treat laws and similar legislation proposed to expand pharmacists’ scope of practice. By passing this legislation and “allowing these nonphysicians to treat any patient over the pharmacy counter for conditions they may not have ever seen before,” patients would be put at risk.1
By reducing pharmacists to “nonphysicians,” the AMA ignores their extensive training and expertise as health care professionals and dismisses the unique value they add to patient care. Additionally, the focus on professional hierarchy—whereby one type of health care provider should rank above another—undermines the shared goal of optimizing patient health outcomes. After all, the patient should always be at the center of care, and a collaborative approach is key to achieving the best results.
In this attempt to feign patient advocacy, the article argued that “while pharmacists are medication experts, they are not trained to take on the role of primary care physician.”1 But was that ever the goal?
Trained to Do Different Things
According to the Board of Pharmacy Specialties, 60,000 pharmacists across the United States have obtained board certification and completed a rigorous process that ensures clinical competency in direct patient care within 14 specialties spanning oncology, psychiatric care, nutrition, cardiology, infectious disease, and critical care.2
Nearly one-third of practicing pharmacists have undergone at least 1 year of postgraduate residency training, with many others pursuing a second year and fellowship training.2 Where the AMA claims that pharmacists’ studies center on “scientific laboratory study,”1 their curriculum reaches much further: It includes training in therapeutic decision-making, understanding social drivers of health, conducting mental and physical assessments, and solving medication-related issues for the sake of patient safety.
“If adequate research had been done, the writer would have identified that student pharmacists receive extensive experiential and simulated patient interactions that involve substantial training on medical information gathering, assessment, planning, and care of patients across the life span for acute and chronic conditions,” Jennifer L. Rodis, PharmD, FAPhA, professor of clinical pharmacy at The Ohio State University in Columbus and president-elect of the Ohio Pharmacists Association, said. “As pharmacists, we are trained to be part of the patient’s team of health care providers, leaning in with our expertise and skills in collaboration with our colleagues to provide holistic care to patients. We are not training pharmacists to draw lines in the sand regarding whose turf is whose while gaps in patient care form between the lines.”
By dismissing pharmacists as “nonphysicians” or limiting pharmacists to the role of medication experts, the AMA undercuts the value that pharmacists bring to patients in their day-to-day practice. “We should never look at a pharmacist as somebody who just knows how a medicine works,” Amy N. Thompson, PharmD, BCACP, clinical associate professor of pharmacy at the University of Michigan in Ann Arbor and director of ambulatory clinical pharmacy practices for Pharmacy Innovations and Partnerships within the University of Michigan Medical Group, said. “When I am looking at a patient’s regimen, I am looking at their medications, I’m thinking about how they interact with each other, how they might interfere with other disease states that patients may have, and what sort of monitoring is needed. I ask questions like, ‘Does the dose need to be adjusted because their kidney function is not as great? Do I have to worry about their liver function? Is this going to make their asthma worse?’”
Outside of filling prescriptions, pharmacists leverage their knowledge and skills in medication education, consultation, and supervision to improve patients’ health outcomes and ultimately their quality of life.
An abundance of clinical literature has demonstrated this effect. A meta-analysis that examined pharmacist influence on type 2 diabetes management across 35 studies found that pharmacist interventions were able to significantly improve hemoglobin A1c, high-density lipoprotein cholesterol, systolic blood pressure, diastolic blood pressure, body mass index, and fasting blood glucose levels.3 What’s more, findings from every study within the meta-analysis that measured medication adherence—a behavior known to reduce patients’ costs associated with unnecessary medical visits and prescription refills—demonstrated positive improvements as a result of the implemented interventions.3,4
Results from another study based in North Carolina found that patients seen by a clinical pharmacist practitioner in a follow-up program had a much lower rate of being readmitted to an ambulatory care setting within 30 days of discharge (9%) compared with those who received usual care (26%). This improvement translated to 1 less readmission for every 7 patients seen at the clinic and a staggering $1,113,000 in estimated annual reduced costs.5
No Room for Expanded Scope
The experiences of the COVID-19 pandemic serve as a direct rebuttal to the AMA’s claims that legislation expanding the scope of practice for pharmacists would endanger patients. At a time when physician visits were limited (and many offices were closed), pharmacies remained open and pharmacists stepped up to provide essential health care services. Through the administration of COVID-19 vaccines, dispensing of antiviral medications, and support of patients, these health care professionals helped avoid more than 1 million deaths, more than 8 million hospitalizations, and nearly $500 billion in health care costs.6
“There [are] a lot of rural communities across this country that would have lost a lot more lives to COVID-19 had pharmacists not been willing to do that testing and provide those vaccines,” Michael D. Hogue, PharmD, FAPhA, FNAP, FFIP, CEO of the American Pharmacists Association, said. “It was an amazing demonstration of the profession’s commitment to serving communities and serving patients. Pharmacists showed us that their knowledge, skills, and abilities are exceptional and that they’re capable of doing a whole lot more than the health system sometimes thinks they can.”
An increase in global proposals to expand pharmacists’ scope of practice further highlights their unrealized potential to contribute more significantly to patient care. The shift directly contradicts the AMA’s assertions that such proposals would be unproductive.
Earlier this year, pharmacists in the United Kingdom received authorization to treat patients with 7 common conditions, including sinusitis, sore throat, earache, infected insect bites, impetigo, shingles, and uncomplicated urinary tract infections. The change is forecasted to free up 10 million appointments at the general practitioner annually, representing a win-win solution for pharmacists, physicians, and patients alike.7
“Great Britain has figured out that by leveraging the role of the pharmacist to prescribe for these common conditions, they can actually free up the health care system so physicians can focus on more acutely sick and difficult patients who need their help,” Hogue explained. Similar plans aimed at expanding the role of the pharmacist and alleviating pressure on the health care system have been enacted in Canada, where all pharmacists hold varying degrees of prescribing authority.8
It may also be of consideration to the AMA that current policies “safeguarding” patients from legislation aiming to expand the scope of pharmacists are the reason why pharmacists are unable to practice at the top of their license. Streamlining regulations that grant the profession payer status, for instance, could allow them to provide even better care.
“A lot of clinical services that pharmacists provide are not reimbursable. And so they’re not sustainable, which contributes to the burnout piece you hear associated with pharmacists,” Thompson said. “Helping us get provider status in the eyes of a payer would be huge, because then we could create sustainable service models that would be more effective in the community.”
Allowing pharmacists to participate in collaborative drug therapy management through collaborative practice agreements could improve outcomes for patients as well. “Having a pharmacist involved in care as part of a collaborative [practice] agreement can relieve burnout for physicians and expand access for patients, ensuring close follow-up during medication titration for conditions such as diabetes and hypertension,” Jill Fenske, MD, family medicine physician and medical director for quality within the University of Michigan Medical Group, said. “Pharmacists also provide valuable education for patients, which improves adherence to physician treatment plans. Patients receive better, more personalized care when we all work together as part of a team.”
A Focus on Collaboration
Although the AMA article frames itself as promoting patient safety, the final result seems to prioritize protecting the turf of physicians ahead of collaborative, patient-centered care. “There is more than enough work to go around, when you think of the fact that 30% of patients don’t even have a primary care physician because they can’t get in [to see one],” Thompson said. “Why are we not working together to improve access?”
Neither the AMA nor the American Pharmacists Association purport to reflect the interests of all physicians or pharmacists.2 This was illustrated in the strong social media response from physicians, many of whom criticized the AMA article. In health care settings across the US, pharmacists and physicians understand that by coming together, they can achieve the shared goal of patient well-being and lean on each other to lessen the stress of their respective professions.
“Pharmacists are vital members of the health care team, and I work collaboratively with pharmacists embedded in primary care to care for patients with chronic conditions, such as diabetes and hypertension,” Fenske said. “Of course, there is a difference in training between pharmacists and physicians, but those differences can be complementary when working together as part of a multidisciplinary health care team.”
Although it is true that pharmacists are not trained to take on the role of primary care physicians, it is also true that pharmacists shouldn’t have to fulfill that position in the first place. Passing legislation that allows pharmacists to practice at the top of their training and licensure and leveraging the unique strengths of each profession in collaboration with the other can set in motion a ripple effect of positive outcomes through the entire health care system.
“The quote from John F. Kennedy, ‘A rising tide lifts all boats,’ strikes me as relevant to describe the intent of an interprofessional team,” Rodis said. “If we practice at the top of our education, with our individual professional expertise and skills and the patient at the center, health care can improve for all.”
References
1. Smith TM. What’s the difference between pharmacists and physicians? AmericanMedical Association. February 5, 2024. Accessed March 8, 2024. https://www.ama-assn.org/practice-management/scope-practice/whats-difference-between-pharmacists-and-physicians
2. Hogue MD, Vermeulen L. AMA statement on pharmacists is arrogant, self-centered, and out of touch. American Pharmacists Association. February 16, 2024. Accessed March 8, 2024. https://www.pharmacist.com/CEO-Blog/ama-statement-on-pharmacists-is-arrogant-self-centered-and-out-of-touch
3. Zhang L, Lin H, Wu W, et al. A meta-analysis of the impact of pharmacist interventions on clinical outcomes in patients with type-2 diabetes. Patient Educ Couns. 2024;120:108091. doi:10.1016/j.pec.2023.108091
4. Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. 2011;26(3):155-159. doi:10.5001/omj.2011.38
5. Hawes EM, Misita C, Burkhart JI, et al. Prescribing pharmacists in the ambulatory care setting: experience at the University of North Carolina Medical Center. Am J Health Syst Pharm. 2016;73(18):1425-1433. doi:10.2146/ajhp150771
6. Grabenstein JD. Essential services: quantifying the contributions of America’s pharmacists in COVID-19 clinical interventions. J Am Pharm Assoc (2003). 2022;62(6):1929-1945.e1. doi:10.1016/j.japh.2022.08.010
7. Over 10,000 NHS pharmacies begin treating people for common conditions. NHS England. January 31, 2024. Accessed March 8, 2024. https://www.england.nhs.uk/2024/01/over-10000-nhs-pharmacies-begin-treating-people-for-common-conditions/
8. Scope of practice. Canadian Pharmacists Association. Accessed March 8, 2024. https://www.pharmacists.ca/advocacy/scope-of-practice/
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