What Do Checklists Say About Our Profession?

Which of the following would come closest to your view of the word “professional?” Someone who uses their education, experience, and judgment to work for the best outcomes in a field where they constantly face unique situations? Or someone who follows checklists that come down from above?

I don’t know about you, but my answer would be the former.

Now, do you consider pharmacists to be professionals?

My answer, along with I’m guessing those of over 99% of the people reading this, would be yes. Which is why I was disturbed to see a checklist one of the “Big 3” pharmacy chains has required its pharmacists to use for the last few years when they are dispensing any of what it calls “target drugs”: oxycodone, hydromorphone, and methadone.

Don’t get me wrong, I am well aware of the opioid crisis in this country. Certainly, the goal of ensuring the appropriate use of narcotics is a laudable one. However, I’m afraid the main idea behind this checklist was covering the company’s rear end, and not improving patient care. But whatever the goal, limiting the ability of a pharmacist to use his or her judgment is in no way compatible with treating pharmacists as the educated professionals we are.

I’ll put aside any problems with the particular checklist I saw. For example: A prescription for 120 tablets would not be a “red flag” for a patient with insurance, but would be for someone without. Perhaps they understood the headaches that can come with dealing with insurance companies, and decided to allow for a greater need for painkillers. The problem is that, quite simply, you cannot come up with a checklist that will work in subjective situations. I guarantee you there are patients out there who find relief from their suffering only with prescriptions that would raise “red flags” under this checklist policy. That’s why it’s perfectly legal for doctors to prescribe drugs “off label” or in doses not recommended in the package insert. What’s a pharmacist who’s covered by this corporate policy to do when one of these patients comes to his or her counter?

The policy I saw said that the checklist “was not a replacement for professional judgment,” but also stated the company was “taking a strict stance on compliance with these requirements.” It also said that, “failure to comply will result in disciplinary action up to and including termination of employment.” This reminds me of a dog that growls at you while wagging its tail. You don’t know which end to believe.

And while many of you will say, rightly, that this checklist mainly contains items that a conscientious pharmacist would be doing anyway, can you be so sure the next checklist will? Or the one after that? The first metrics I saw when I worked for the chains were reasonable, but by the time I left they had descended into the ridiculous, actually hampering our ability to provide good service to our patients and doing a great deal to damage my image as a professional.

If you want to solve this problem I’ll provide a policy right now that will do just that. “All prescriptions will be filled at the sole discretion of the pharmacist on duty, who alone will bear all responsibility for the consequences of their decisions.” One sentence provides the cover the corporate chains want while moving the role of the pharmacist back towards the direction of a true professional.

It is, however, the exact opposite direction I’m afraid those who run our profession want to go.