Doctors versus pharmacists: common sense must prevail

Given recent headlines, one could be forgiven for thinking that GPs like myself are spending their days bickering on the phone with pharmacists and refusing to collaborate in patient care. The reality couldn’t be further from the truth; most GPs and pharmacists work together seamlessly most of the time. We ensure scripts are renewed and medication lists updated, Webster packs adjusted, and home medication reviews attended for patients with chronic diseases and complex medication regimens. Collegiate phone calls are had, letters are exchanged, and every working day we provide care to our shared patients within an imperfect and under-resourced health system. Together we navigate medication shortages, ever changing Pharmaceutical Benefits Scheme requirements and the logistics of getting antiviral medications to patients with coronavirus disease 2019 (COVID-19).

Our roles are inextricably linked and we rely heavily on one another to deliver health services, but who exactly should be delivering what services has become such a heated topic that tensions are reported to be at boiling point and the rhetoric escalates with every breaking story.

It must look terribly unprofessional from the outside, after all, aren’t we all meant to share the common goal of patient care? And if so, how can the view of doctors and pharmacists be so polarised?

A vocal pharmacy lobby

One reason is that that the loudest voices are the most extreme. The Pharmacy Guild of Australia has become a roaring force in this debate. Just last week, Pharmacy Guild president Trent Twomey was visibly distressed on national television at the prospect of a 60-day script-renewal plan that will allow millions of Australians with chronic illnesses to halve their medication costs and reduce the required visits to pharmacies. This change is undisputedly good for patients, less out-of-pocket costs and less time spent travelling and waiting in line at the pharmacy. However, as this threatens to reduce income for pharmacies, it was slammed by pharmacy lobbyists – although it should be noted that the Health Minister did commit to reinvesting all cost savings back into community pharmacies.

Just a few months earlier, Twomey was also quoted as saying he needed to be able to prescribe and administer “all medicines for all people”. There is no doctor in the country with the authority to prescribe all medicines for all people, but despite this, one of the highest profile pharmacists appears to believe this should be within his scope of practice. The weight of responsibility of such a job would be overwhelming to anyone who understands what responsible prescribing entails, but as the old saying goes, you don’t know what you don’t know.

The pitfalls of prescribing

Nevertheless, community pharmacists are eager to participate in prescribing schemes as it presents an opportunity for professional development and role diversification. However, the conflict of interest when both prescribing and dispensing medications remains deeply problematic, as recommending a certain treatment could financially benefit the prescriber in this setting. Beyond this, we are dealing with proposals that involve medical conditions that are not straightforward to diagnose or treat. For example, the Queensland pharmacy prescribing pilot includes infections such as otitis media and otitis externa — differentiating the two is impossible when you have never used an otoscope before.

The current Therapeutic guidelines also recommend that the mainstay of treatment for acute otitis media is adequate and regular analgesia, with most patients not needing treatment with antibiotics. As such, pharmacists ironically can already treat the majority of cases, and those who need antibiotics are at higher risk of complications and should be reviewed by a doctor regardless. This is just one of many examples where pharmacy prescribing simply doesn’t make medical sense.

In addition, these pilots and trials are effectively paving the way for antibiotics to become over-the-counter medicines, which will be a disaster for antimicrobial resistance, one of the world’s most urgent public health concerns.

The Australian Medical Association has launched a refreshingly measured “You deserve more” campaign that puts forward the very real threats to patient safety and our health system if pharmacy prescribing expands. It is interesting to hear pharmacist turned GP Dr Nicholas Yim present a relatively common case in general practice that would have likely resulted in a critical missed diagnosis and useless script for trimethoprim if dealt with in a pharmacy.

What is best for patients?

One voice that is seemingly quiet from the discourse is that of patients. We can assume from the uptake of the Queensland pharmacy prescribing pilot, where almost 10 000 women with possible urinary tract infections (UTIs) used the service, that there is demand. What we don’t know is whether these women preferred to see a GP but were unable, and whether these patients even had UTIs.

Despite many unknowns, doctors must be wary of falling into the trap of thinking in black and white terms when it comes to pharmacy services. Medications already available without prescription, such as salbutamol inhalers and adrenaline auto-injectors, are life-saving. Others, such as chloramphenicol eye drops and ointment, do not seem to cause any significant harm — although the ointment is frequently recommended and dispensed for skin infections, which is another reason we need to tread carefully in broadening the range of medications available from pharmacies.

Being able to get immunised against influenza and COVID-19 at the pharmacy makes complete sense, extending this to include certain travel vaccinations seems logical. Furthermore, while a consultation for a prescriptions for the oral contraceptive pill is a great opportunity to ensure preventive health checks are attended to, it does not necessarily justify restricting access to contraceptive options for women. It is interesting to note that, globally, over 100 countries now offer oral contraceptive pills over the counter, and there are safety checks and balances that can be effectively implemented to ensure harm minimisation such as self-screening tools.

The common thread in such examples is that these services utilise the expertise and skill set of our pharmacist colleagues, and do not go beyond them by requiring diagnostic skills that are honed over many years of education, intensive training and rigorous assessments that are currently unique to medical schools and specialist training pathways.

It is time to dull the noise and go back to basics, we need a common-sense approach to policy when it comes to medication prescribing and dispensing. Pharmacists play a valuable and critical role in our health care system. For GPs, it is a familiar feeling to work in a role that is often disrespected and underappreciated, and it is not a feeling we wish on our colleagues. However, after completing specialist training and developing a skill set that allows for accurate diagnosis and, therefore, appropriate treatment, we are acutely aware of what is at stake if prescribing is coupled with dispensing rather than diagnostic ability. We need the rhetoric to slow down, for patients to be heard and for politicians and health leaders to be reminded of what it is we should all be striving for: a world-class health system with positive health outcomes. This requires a strong primary care network that is underscored by the basic tenets of universal health care by putting patients before profits and safety first. Doctors and pharmacists have worked together to get us this far, let’s continue to do so.

Dr Alisha Dorrigan is a Sydney-based GP.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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