Is Community-Based Pharmacy Practice Holding Itself Back?

A man and his son were in a terrible car accident. The man died on the way to the hospital, and the boy was rushed into surgery. The surgeon refused to operate, however, stating honestly, “I can’t operate on him because he’s my son!” How is this possible?

UNCONSCIOUS BIAS IS INSIDIOUS, PREVALENT AND NORMAL

The riddle above is a popular Psychology 101 lesson in unconscious bias. Strong majorities of participants in a study could not process, let alone answer, the riddle.¹ To those of you in the minority of 15% to 20%, according to the study findings, who realized that the surgeon could be the son’s mother (or other relationship), congratulations!

Those of you who furrowed your brow and scratched your head can take some measure of comfort in the fact that you are not alone. However, this is a great reminder that unconscious bias is common and apparently part of normal human development, based on the theory that we are conditioned by our consumption of information and everyday experiences. What we see is what we learn to believe.

SCHEMATA ARE POWERFUL INFLUENCERS IN PHARMACY

Variations of these bias experiments and riddles have been published in peer-reviewed journals, validating that schemata are incredibly powerful influencers of behavior, even among those who genuinely profess to be unaffected or unbiased by a schema. This mental framework allows taking a shortcut during information processing to come to an expedient conclusion. It is derived from previous conditioning or experience and can quickly overpower evidence and facts that lead to a contrary conclusion. A schema is a cousin of prejudice and an in-law of cognitive dissonance.

PREVAILING COMMUNITY PHARMACY PRACTICE SCHEMATA

Ask most pharmacists what they think of when they think of community pharmacy practice and they will reflexively respond that it is limited to effective dispensation of medications. Most pharmacists maintain an unconscious bias that severely inhibits the ability to evolve community pharmacy practice into sustainable service models rooted in care delivery. Whether it is the health-system pharmacist skeptical of the clinical capabilities of the community pharmacist, the pharmacy director at the insurance company, or the professor steering a student away from community pharmacy practice, self-reinforced schemata about community pharmacy practice are self-defeating and troublesome.

Unfounded Schema No.1: Community Pharmacists Are Not Capable of Clinical Practice

It always saddens me to see colleagues in all tribes of pharmacy practice eschew the capabilities of community pharmacy practitioners, who also often underestimate themselves. As someone who grew up with primary care physicians and is a lifelong fan of family medicine practice, I am reminded of the “generalist” versus “partialist” barbs and gripes between primary care and specialty physicians, with neither having respect or a nuanced appreciation for the skill required in others’ practices.

For generalists, the challenge is getting partialists to understand the importance of the whole patient and the magnitude of everything that can impede care: cultural barriers; drug interactions; lack of coverage, treatment, transportation, and access to care, as well as confidence and trust; illiteracy; life management; poor self-administration; regimen complexity; and other therapeutic conflicts or misadventures. These challenges are abundant in our patient panels, and generalists take the broader view and address items within their capabilities.

So, why would anyone think that community pharmacists are not capable of general pharmacist practitioner services? Surely community pharmacists can create a plan of care and coaching for a glycated hemoglobin level that is out of range or take, interpret, and act on blood pressure (BP) readings. Why must one be a therapeutic expert to engage in “clinical” practice? The organ transplant pharmacist at the local health system might be a top-notch therapeutic expert, but to consider that person a standard-bearer for general pharmacy practice is silly.

There are 75 million Americans with high BP,² 84 million with prediabetes, and 30 million with diabetes.³ Surely pharmacists at 65,000 community-based sites of care are competent enough to evaluate out-of-range readings and act to change a patient’s plan of care, titrate medications, or refer to a physician or pharmacist specialist when an evaluation exceeds their capabilities or comfort level. Primary care physicians do the same during millions of patient encounters every day.

Unfounded Schema No.2: Community Pharmacies Are Not Ideal Clinical Practice Settings

The idea that pharmacists must be in a setting that looks like a hospital or physician’s office to provide pharmacist-delivered services is another self-defeating preset schema. No doubt amazing pharmacists are doing amazing work in those places, but why limit pharmacist care delivery to a small number of settings that are often many miles or counties away from where patients live? Proximity to the prescriber has many benefits, of course, but again, the nearly half of our adult population with diabetes or hypertension can receive all sorts of helpful care delivery without a prescriber on the other side of the wall.

To expect the same in physician practice would be to relegate a family medicine practice to some measure of proximity to a colonoscopy clinic, an MRI machine, or a retinal scanner. I think primary care physicians can do fine on their own and refer to a specialist when needed.

Unfounded Schema No.3: Patients Do Not Want to Receive Health Care Services in a Pharmacy by a Pharmacist

Not long ago, a self-reinforced pharmacist schema could not fathom a patient receiving an immunization in a pharmacy. However, the much more prevalent patient-consumer schema asked, “Why not?” It was not a stretch for the consumer to conceive of pharmacies as sites of care, yet many pharmacists had formed a mental block about providing immunizations at their practice sites. The patient’s schema often views the potential for pharmacy practice to be much more progressive than do the pharmacists in those settings.

Community pharmacy is, by billions of visits, a more accessible and frequented site of care, staffed by some of the most capable and best-trained practitioners in the entire health care system. And patients want care delivered there.

JD Power recently found that 9 of 10 pharmacist-patient interactions remain in a community pharmacy,4 and patients cherish face-to-face interaction. Ratings were higher if multiple topics were discussed. The entire premise of CVS’ 1500 health hubs, soon to be rolled out, is based on strong consumer evidence that pharmacies are a desired site of care for health and wellness products and services.

ONE GROUP SHOWS WHAT COMMUNITY PHARMACY CAN BE

At Kelley-Ross, a pharmacy group based in Seattle, Washington, HIV pre-exposure prophylaxis (PrEP) is one of the most popular health care services. I had the occasion to visit the pharmacy last spring, and what I saw was inspiring. It changed some of my own misguided schemata about community pharmacy practice.

The pharmacy has a room that looks a lot like an exam room, with an electronic medical record and a full-time patient services representative/scheduler. The pharmacists are credentialed as providers of care, and the pharmacy is booked solid for HIV PrEP services every week. Kelley-Ross has an amazing staff of clinician pharmacists that would make a PG2 residency director blush.

Asked how this pharmacy-based and -staffed clinic came to pass, Ryan Oftebro, chief executive officer of Kelley-Ross, said, “It’s about people and their mindset. We have created a culture of leadership throughout our team that seeks out opportunities and challenges the status quo. Our staff came up with this entire model. The role of the senior leadership in our organization was to reduce friction and provide resources. Focusing on public health—related issues and underserved populations has helped build relationships and create community engagement, which has been critical to our success. The pharmacy is an advantageous and sustainable site of health care services. We just need more pharmacy owners to believe it’s possible.”

CONSTANT VIGILANCE MUST BE MAINTAINED

Sociologists warn that, without constant vigilance, unconscious bias remains entrenched. For those who want to break out of an existing schema, experts offer a few suggestions:

Amplify countervailing voices. Find patients who either receive or want to receive services at the pharmacy and have them share that with your staff. Hearing about patient desires and needs that are counter to the existing and limited practice schema will help build a new practice schema.

Change the environment. Convenience does not necessarily mean retail. Patients want an inviting environment that feels competent and trustworthy. Place certifications and licenses out front in the exam room, not behind the counter. Celebrate and show off the staff’s skills.

Change the language. Notice that I did not say “counseling room”? This is an exam room where a lot of healthy counseling takes place. To quote Aerosmith: “Walk this way. Talk this Way.”

Get exposed to counterprogramming. This requires more than seeing a community pharmacy get an award for progressive practice at a trade show. Have staff members imagine that they are delivering health care services during counseling or encourage them to conceive of a new service.

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with mroe than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

REFERENCES

• Tuckey MR, Brewer N. The influence of schemas, stimulus ambiguity, and interview schedule on eyewitness memory over time. J Exp Psychol Appl. 2003;9(2):101-118. doi: 10.1037/1076-898x.9.2.101.
• Merai R, Siegel C, Rakotz M, et al. CDC grand rounds: a public health approach to detect and control hypertension. MMWR Morb Mortal Wkly Rep. 2016;65(45):1261-1264. doi: 10.15585/mmwr.mm6545a3.
• National diabetes statistics report, 2017. CDC website. cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed January 2, 2020.
• Pharmacy customers slow to adopt digital offerings but satisfaction increases when they do, J.D. Power finds [news release]. Costa Mesa, CA: J.D. Power; August 20, 2019. jdpower.com/business/press-releases/2019-us-pharmacy-study. Accessed January 2, 2020.