What Is Pharmacy Practice?

As the health care system changes, the line between the roles of pharmacist and physician can become blurred.

I recently suggested that there might be a role for pharmacists in primary care. I was surprised by the number of readers who responded. Many offered comments such as, “Most pharmacists want to be pharmacists, not doctors” or “That’s the problem our profession (has) today. We have bought into this sales pitch that pharmacists, in order to stay in business, must play MD, PA, or NP...No to pharmacist/MD. I am a pharmacist.” This theme of “I am a pharmacist and if I wanted to be a doctor I would have gone to medical school” was loud and clear. The fact that pharmacists really want to be pharmacists is good for our profession.

But is assuming a primary care role taking on physician roles, or is it just expanding our own role as the health care system changes? What differentiates a pharmacy role from a medical role? A simple answer is that what the state licensing laws allow each profession to perform provides that differentiation. However, over my 50 years in practice, legislative changes in practice acts have tended to blur the differentiation. Perhaps this is best illustrated by the expanded role pharmacists are playing in vaccine administration.

Some might suggest that the difference occurs because physicians are “independent practitioners” who direct “dependent practitioners” like pharmacists to take action. I agree that many pharmacists see themselves in this role. In my pharmacy training this was certainly the model I was taught to follow. Even today, pharmacists look to physicians to endorse or approve their actions. However, many pharmacists act independently in some of the roles they undertake. When you triage a patient who comes in for advice with a clinical problem and you send them to a physician, you may be acting as a dependent practitioner. But when you recommend a treatment for the problem, you are acting as an independent practitioner. As the FDA and some states move toward a class of drugs that pharmacists can prescribe/recommend, the line between physician and pharmacist blurs yet again.

Community pharmacy is positioning itself as the neighborhood community health center, often by placing ambulatory care centers run by nurse practitioners (NPs) or physician assistants (PAs) within the community pharmacy—helping to continue to blur the lines between professions. As these centers begin taking care of chronic disease, who should take care of these patients—the pharmacist or the NP? When managing chronic disease, is the pharmacist acting as a dependent or independent practitioner? If the patient volume does not support 2 different practitioners, would the pharmacist or NP be the better practitioner to employ? Of course, right now it is the NP because the pharmacist is not recognized as a primary care practitioner. The case I am trying to make is that the pharmacist with expanded skills might be the best type of practitioner to use to help the patient manage their chronic diseases. One reader said “Where I can see pharmacy making huge strides is not so much in diagnosis, but in management”—and I agree. My concern is that we end up being left out of this role because we are not able to take on this expanded role in primary care.

Chronic disease management is where I want pharmacists to be able to function. What is the best way to make this happen? Today’s student pharmacist is being trained to perform this role very well. Although I argue that chronic disease management is the practice of pharmacy, some pharmacists may consider it to be the practice of medicine because it was not the role they were trained to do in pharmacy school. One reader said, “I believe this is the future of our profession. I feel so strongly about this I went back to school to get a bachelor’s in nursing and I am about a year away from graduating with my master’s of science in nursing focusing on becoming a family nurse practitioner.”

This was not what I had in mind when I suggested some more training! A theme being heard more frequently is the need for cross-training of health care workers.

I am proposing that some cross-training would make pharmacists a better fit to provide certain primary care functions to better assure their role in chronic disease management. I do not want to get pharmacists into a turf battle with or alienate other health care professionals. But until each team member is truly recognized and fully utilized, we have to push the edge to allow pharmacists to practice at the top of their license. That is what I want to see happen. Like most of you, I do not want to make pharmacists into physicians.