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The Pharmacist In a Family Medicine Setting
PHARMACY & FAMILY PRACTICE
The Pharmacist In a Family Medicine Setting By C. WAYNE WEART
S
ignificant advances have occurred in the field of clinical pharmacy over the past decade, particularly with respect to the role of the pharmacist. But while new roles have flourished in the major medical centers, there has not been a largescale transfer of these roles into the community where the majority of drugs are prescribed and dispensed, and where more than 90% of all patients seeking health care can be found. Drug-induced illness is a leading cause of hospitalization. Melmon estimated 3-5% of all hospital admissions are drug related. 1 More recently, Steel found that 36% of general medical patients had iatrogenic illness or drug-induced disease. 2 These patients have potentially preventable illnesses. With the recognition of the problem C!nd involvement of the community-based practitioner, hospitalization may be avoided. Health care is being affected by the current economic slowdown. Physician visits continue to decline, patients are more likely to seek information on self-care, and thirdparty coverage is decreasing while costs continue to climb. These factors place an increasing responsibility on the communitybased health care provider and present greater than ever demands and opportunities for ambulatory clinical pharmacy services.
Family Medicine Family medicine is one area of ambulatory clinical pharmacy practice that has seen significant growth in the last 10 years, allowing pharmacists to bridge the gap between traditional community practice and
American Pharmacy Vol. NS23, No. 5, May 1983/237
clinically oriented institutional practice. Family physicians are the major prescribers of medications today and are responsible for comprehensive and continuing health care for patients from the time of conception through the geriatric years. They are involved in health promotion, prevention, health maintenance, early detection, curative therapy, disease management, and rehabilitation. Family physicians routinely seek consultation with other health professionals to help solve or manage difficult and/or complex problems. These physicians are team oriented and anxious to seek the pharmacist's advice and help when it comes to drug therapy. A recent survey of 72 family medicine residents in North Carolina identified the curricular content areas they deemed most important (see table on p. 30).3 Six of the top seven areas identified provide an oppor-
c. Wayne Weart, PharmD, is associate professor in the department of family medicine, College of Pharmacy, Medical University of South Carolina , Charleston, SC 29425.
tunity for pharmacist involvement, with the second most important area being clinical thera peu tics. In general, family physicians' attitudes support clinical pharmacy. Their awareness of the scope of pharmacy services is usually improved by direct contact with clinical pharmacists, as was demonstrated in a survey of family medicine residents and private practice physicians in Iowa. 4 Physicians exposed to clinical pharmacists during training or while in practice were more likely to perceive the role and activities of the clinical pharmacist as beneficial, and they were more likely to consider incorporating a clinical pharmacist into their private practice. Further, the president of the Society of Teachers of Family Medicine said recently that pharmacists with clinical expertise should be filling a third of the approximately 1,500 vacant family medicine faculty positions. 5 The teaching contributions made by clinical pharmacists in family medicine residency training programs are highly valued. 4 In the department of family medicine at the Medical University of South Carolina, a clinical pharmacist has been named the outstanding clinical teacher by the graduating residents for two consecutive years.
Patient Attitudes Patient attitudes toward clinical pharmacy services in family medicine centers are generally favorable. Preliminary results of a recent survey of the attitudes of patients using five private family medicine centers in South Carolina show that when given the choice, 83% of the patients took advantage of the pharmacy ser29
Cunicular Content Areas Identified As Most IDlportant by Residents Items Diagnosis of common illnesses Clinical therapeutics Managemen t of chronic disease Management of common acute problems of adults Team approach to health care .Scores are means based on
ascale of 1 =
2.01 2.07
Items Patient education and compliance Management 'of common acute problems of children Preventive health care " Interviewing techniques Fami!y dynamics
score* 2.10 2.19 2.26 2.28 2.34
a great deal, 2 = frequently, 3 = occasi? nalJy, 4 = hardly ever, and 5 = never.
vices provided in the family medicine centers. Four of the five centers incorporate clinical pharmacists as an integral part of the practice. One center without pharmacy services served as a control (see table below). 6 Eighty-one percent of the patients felt that the pharmacy services received in the four centers that had clinical pharmacists were better than those received previously in the community. A total of 86% of these patients believed that the pharmacist should review and evaluate their medical records prior to dispensing any medication. The family medicine setting facilitates the development of a continuing pharmacist-patient relationship which allows the pharmacist to provide clinical services in the primary care setting. The pharmacist has the advantage of knowing and following the patients when they are well, when the decision is made to admit, when hospitalized, and when discharged. Our institution-based pharmacy colleagues generally have clinical involvement only during hospitalization. They have minimal knowledge of the patient prior to admission and little follow-up after discharge.
Family Practice Roles While functions may vary depending on the practice setting, and not all functions are feasible in some centers, they should include patient care services, services for health professionals, and research . Patient Care Services. These may be provided in the family medicine
30
Score * 1.75 1.93 2.01
center, the patient's home, nursing home, or hospital. Patient care responsibilities include, but are not limited to: • Monitoring drug therapy. This includes assessment of drug therapy for appropriateness, effectiveness, compliance, dosage, drug interactions, pharmacokinetics, adverse reactions, and laboratory parameters, and updating the patient's medical record. • Therapeutic and pharmacokinetic consultations. These are the major components of clinical pharmacy involvement in patient care. Pharmacokinetic consultations may include the provision of serum drug assays. Ideally, the pharmacist should be involved in the decision to obtain a serum drug level, the most appropriate time to obtain the sample, assessment of compliance, and evaluation of the
serum drug level. • Dosage calculation. Determination of appropriate dosage may be assumed by the pharmacist when authorized by the physician . • Office laboratory. Pharmacists can coordinate procedures including throat and urine cultures and may be responsible for follow-up contact and treatment. • Telephone triage. Drug-related telephone calls can be referred to the pharmacist, who may be able to determine whether the patient needs to be seen or if the problem can be managed at home with a non prescription medica tion . Pharmacists can also assist in the assessment of patient's response to a new medication by phoning the patient several days after beginning therapy. • Home visits. Pharmacists, physicians, and/or nurses may be re-
elil Attitudes tenters withou t clinical pharmacy service* (N = ZO)
Overall rating of pharmacy services Excellent Good Fair Poor Patient feels better about his or her health after viSIting with pharmacist
68.8% 30.8% 0.4% 0.0%
32.9% 45.7% 21.4% 0.0%
82%
31 %
· Pa tients were asked to evaluate the commu nity pha rmacy where they receive pharmaceu tica l services.
American Pharmacy Vol. NS23, No. 5, May 1983/238
quired to make home visits to patients who find it difficult to get to the physician's office. • Medication histories . The pharmacist may obtain and record patient medication histories both in the fa mily medicine center and on admission to the hospital. • Patient education services. These educational services may be provided on an individual basis, in small groups or classes, or via the media (pamphlets, newspaper, radio, or television). Areas of potential education include, but are not limited to, medications, medical devices and appliances, compliance, disease states, health promotion, health care use, dietary counseling, substance abuse, and cardiopulmonary resuscitation. • Liaison with community pharmacists. Patients who elect to receive prescription services from a pharmacy outside the group practice may still be counseled by the group pharmacist and have the prescriptions assessed for completeness prior to leaving the practice. Community pharmacists are encouraged to con tact the group's pharmacist should any questions or problems arise. Services for Health Professionals. • Physician education. Pharmacists can provide much needed drug information to the busy family physician who has little time to keep current with the numerous advances in pharmacotherapeutics. The information presented by the pharmacist should assist the prescribing physician in making a rational decision concerning drug therapy. Specific areas may include basic pharmacology, indications, precautions, efficacy of a particular agent or class of agents, dosage (including dosage formulation and appropriate dosage interval), adverse reactions, and appropriate monitoring parameters. • Pharmaceutical sales representative presentations. The pharmacist can be an invaluable resource to the physician and supplement the drug information that is traditionally provided by medical or phar-
American Pharmacy Vol. NS23, No . 5, May 1983/239
maceutical sales representatives. Further, the pharmacist can meet with the representatives and evaluate the information they plan to present to the physician. • Product selection. Physicians are generally not aware of potential problems in bioequivalence and/ or medication costs. The pharmacist is in tune to which medications are therapeuticall y equivalent but less expensive to the patient. A medication formulary for the group practice can be implemented to achieve the most effective drug therapy at the lowest cost to the patient. • Therapeutic or drug-related conferences , newsletters, etc. The phar-
The family medicine setting facilitates the development of a continuous pharmacist-patient relationship. macist is in the best position to provide information contained in these sources to the physicians, nurses, and other health care providers in the community. Presenta tions can be made during morning rounds, at staff meetings, journal clubs, or scheduled conferences. • Drug information for nurses. Nurses have assumed an increasing responsibility for patient education in many practices. Good personal in teraction and drug information exchange between nursing and pharmacy is essential. Research. Research is most likely to be encouraged in a family medicine residency training program, but it is still possible in a private practice setting. The pharmacist should encourage and participate in health care research in the practice and may serve as a resource for the physician with an idea or project. In addition to original research and pharmaceutical company protocols
or contracts, the pharmacist can participate in scholarly activity by preparing case report s , literature reviews, practice descriptions, and/ or evaluations.
Reimbursement The question of reimbursement, including third-party payment for ambulatory clinical pharmacy services, has yet to be answered adequately. Currently, selected pharmacists are reimbursed for therapeutic and/or pharmacokinetic consultations either by a separate patient charge or by a fee generated within the practice that is included as part of the physician's fee or office visit. There may also be a fee for establishing a chart and obtaining a medication history when enrolling as a patient in the practice. Other examples of reimbursable services in selected practices include blood pressure checks, compliance counseling, chronic medication management, and patient education. Ambulatory clinical pharmacy services both in the academic and private sectors will continue to expand and vary in scope. Some pharmacists in the family medicine setting provide patient monitoring services and/or direct patient care functions while others primarily serve as pharmacotherapeutic consultants. Clinical pharmacy referral clinics and shared clinical pharmacy services by two or more group practices have been established. Pharmacist involvement in a family medicine setting has generally been perceived as beneficial by the pharmacist, physician, nurse, and patient, and should ultimately result in improved health care. D
References 1. K. L. Me lma n, Nt"ll' Ellxlalld jOlinIal of Mt'dicillt', 284 , 1361 (1971) . 2. K. Steel, t't al. , New Ellxla lld jOlinIal of Medicillc, 304 , 638 (1981). 3. F. T. Stritte r a nd R. M. Bake r, jOllnwl of Mcdical Edl/ catiOIl , 57, 33 (1982) . 4. D . K. Helling, Oms Illtellixt.'llce alld Clillical Pharlllacy , 16, 35 (1982). 5. B. M. Eiche lberge r, American journal of Hospital Pharmacy , 37, 740 (1980). 6. C . P. Reid , E. D. Sumne r, and C. W. Wea rt, pa pe r in pre pa ration.
31
The Pharmacist In a Family Medicine Setting By C. WAYNE WEART
S
ignificant advances have occurred in the field of clinical pharmacy over the past decade, particularly with respect to the role of the pharmacist. But while new roles have flourished in the major medical centers, there has not been a largescale transfer of these roles into the community where the majority of drugs are prescribed and dispensed, and where more than 90% of all patients seeking health care can be found. Drug-induced illness is a leading cause of hospitalization. Melmon estimated 3-5% of all hospital admissions are drug related. 1 More recently, Steel found that 36% of general medical patients had iatrogenic illness or drug-induced disease. 2 These patients have potentially preventable illnesses. With the recognition of the problem C!nd involvement of the community-based practitioner, hospitalization may be avoided. Health care is being affected by the current economic slowdown. Physician visits continue to decline, patients are more likely to seek information on self-care, and thirdparty coverage is decreasing while costs continue to climb. These factors place an increasing responsibility on the communitybased health care provider and present greater than ever demands and opportunities for ambulatory clinical pharmacy services.
Family Medicine Family medicine is one area of ambulatory clinical pharmacy practice that has seen significant growth in the last 10 years, allowing pharmacists to bridge the gap between traditional community practice and
American Pharmacy Vol. NS23, No. 5, May 1983/237
clinically oriented institutional practice. Family physicians are the major prescribers of medications today and are responsible for comprehensive and continuing health care for patients from the time of conception through the geriatric years. They are involved in health promotion, prevention, health maintenance, early detection, curative therapy, disease management, and rehabilitation. Family physicians routinely seek consultation with other health professionals to help solve or manage difficult and/or complex problems. These physicians are team oriented and anxious to seek the pharmacist's advice and help when it comes to drug therapy. A recent survey of 72 family medicine residents in North Carolina identified the curricular content areas they deemed most important (see table on p. 30).3 Six of the top seven areas identified provide an oppor-
c. Wayne Weart, PharmD, is associate professor in the department of family medicine, College of Pharmacy, Medical University of South Carolina , Charleston, SC 29425.
tunity for pharmacist involvement, with the second most important area being clinical thera peu tics. In general, family physicians' attitudes support clinical pharmacy. Their awareness of the scope of pharmacy services is usually improved by direct contact with clinical pharmacists, as was demonstrated in a survey of family medicine residents and private practice physicians in Iowa. 4 Physicians exposed to clinical pharmacists during training or while in practice were more likely to perceive the role and activities of the clinical pharmacist as beneficial, and they were more likely to consider incorporating a clinical pharmacist into their private practice. Further, the president of the Society of Teachers of Family Medicine said recently that pharmacists with clinical expertise should be filling a third of the approximately 1,500 vacant family medicine faculty positions. 5 The teaching contributions made by clinical pharmacists in family medicine residency training programs are highly valued. 4 In the department of family medicine at the Medical University of South Carolina, a clinical pharmacist has been named the outstanding clinical teacher by the graduating residents for two consecutive years.
Patient Attitudes Patient attitudes toward clinical pharmacy services in family medicine centers are generally favorable. Preliminary results of a recent survey of the attitudes of patients using five private family medicine centers in South Carolina show that when given the choice, 83% of the patients took advantage of the pharmacy ser29
Cunicular Content Areas Identified As Most IDlportant by Residents Items Diagnosis of common illnesses Clinical therapeutics Managemen t of chronic disease Management of common acute problems of adults Team approach to health care .Scores are means based on
ascale of 1 =
2.01 2.07
Items Patient education and compliance Management 'of common acute problems of children Preventive health care " Interviewing techniques Fami!y dynamics
score* 2.10 2.19 2.26 2.28 2.34
a great deal, 2 = frequently, 3 = occasi? nalJy, 4 = hardly ever, and 5 = never.
vices provided in the family medicine centers. Four of the five centers incorporate clinical pharmacists as an integral part of the practice. One center without pharmacy services served as a control (see table below). 6 Eighty-one percent of the patients felt that the pharmacy services received in the four centers that had clinical pharmacists were better than those received previously in the community. A total of 86% of these patients believed that the pharmacist should review and evaluate their medical records prior to dispensing any medication. The family medicine setting facilitates the development of a continuing pharmacist-patient relationship which allows the pharmacist to provide clinical services in the primary care setting. The pharmacist has the advantage of knowing and following the patients when they are well, when the decision is made to admit, when hospitalized, and when discharged. Our institution-based pharmacy colleagues generally have clinical involvement only during hospitalization. They have minimal knowledge of the patient prior to admission and little follow-up after discharge.
Family Practice Roles While functions may vary depending on the practice setting, and not all functions are feasible in some centers, they should include patient care services, services for health professionals, and research . Patient Care Services. These may be provided in the family medicine
30
Score * 1.75 1.93 2.01
center, the patient's home, nursing home, or hospital. Patient care responsibilities include, but are not limited to: • Monitoring drug therapy. This includes assessment of drug therapy for appropriateness, effectiveness, compliance, dosage, drug interactions, pharmacokinetics, adverse reactions, and laboratory parameters, and updating the patient's medical record. • Therapeutic and pharmacokinetic consultations. These are the major components of clinical pharmacy involvement in patient care. Pharmacokinetic consultations may include the provision of serum drug assays. Ideally, the pharmacist should be involved in the decision to obtain a serum drug level, the most appropriate time to obtain the sample, assessment of compliance, and evaluation of the
serum drug level. • Dosage calculation. Determination of appropriate dosage may be assumed by the pharmacist when authorized by the physician . • Office laboratory. Pharmacists can coordinate procedures including throat and urine cultures and may be responsible for follow-up contact and treatment. • Telephone triage. Drug-related telephone calls can be referred to the pharmacist, who may be able to determine whether the patient needs to be seen or if the problem can be managed at home with a non prescription medica tion . Pharmacists can also assist in the assessment of patient's response to a new medication by phoning the patient several days after beginning therapy. • Home visits. Pharmacists, physicians, and/or nurses may be re-
elil Attitudes tenters withou t clinical pharmacy service* (N = ZO)
Overall rating of pharmacy services Excellent Good Fair Poor Patient feels better about his or her health after viSIting with pharmacist
68.8% 30.8% 0.4% 0.0%
32.9% 45.7% 21.4% 0.0%
82%
31 %
· Pa tients were asked to evaluate the commu nity pha rmacy where they receive pharmaceu tica l services.
American Pharmacy Vol. NS23, No. 5, May 1983/238
quired to make home visits to patients who find it difficult to get to the physician's office. • Medication histories . The pharmacist may obtain and record patient medication histories both in the fa mily medicine center and on admission to the hospital. • Patient education services. These educational services may be provided on an individual basis, in small groups or classes, or via the media (pamphlets, newspaper, radio, or television). Areas of potential education include, but are not limited to, medications, medical devices and appliances, compliance, disease states, health promotion, health care use, dietary counseling, substance abuse, and cardiopulmonary resuscitation. • Liaison with community pharmacists. Patients who elect to receive prescription services from a pharmacy outside the group practice may still be counseled by the group pharmacist and have the prescriptions assessed for completeness prior to leaving the practice. Community pharmacists are encouraged to con tact the group's pharmacist should any questions or problems arise. Services for Health Professionals. • Physician education. Pharmacists can provide much needed drug information to the busy family physician who has little time to keep current with the numerous advances in pharmacotherapeutics. The information presented by the pharmacist should assist the prescribing physician in making a rational decision concerning drug therapy. Specific areas may include basic pharmacology, indications, precautions, efficacy of a particular agent or class of agents, dosage (including dosage formulation and appropriate dosage interval), adverse reactions, and appropriate monitoring parameters. • Pharmaceutical sales representative presentations. The pharmacist can be an invaluable resource to the physician and supplement the drug information that is traditionally provided by medical or phar-
American Pharmacy Vol. NS23, No . 5, May 1983/239
maceutical sales representatives. Further, the pharmacist can meet with the representatives and evaluate the information they plan to present to the physician. • Product selection. Physicians are generally not aware of potential problems in bioequivalence and/ or medication costs. The pharmacist is in tune to which medications are therapeuticall y equivalent but less expensive to the patient. A medication formulary for the group practice can be implemented to achieve the most effective drug therapy at the lowest cost to the patient. • Therapeutic or drug-related conferences , newsletters, etc. The phar-
The family medicine setting facilitates the development of a continuous pharmacist-patient relationship. macist is in the best position to provide information contained in these sources to the physicians, nurses, and other health care providers in the community. Presenta tions can be made during morning rounds, at staff meetings, journal clubs, or scheduled conferences. • Drug information for nurses. Nurses have assumed an increasing responsibility for patient education in many practices. Good personal in teraction and drug information exchange between nursing and pharmacy is essential. Research. Research is most likely to be encouraged in a family medicine residency training program, but it is still possible in a private practice setting. The pharmacist should encourage and participate in health care research in the practice and may serve as a resource for the physician with an idea or project. In addition to original research and pharmaceutical company protocols
or contracts, the pharmacist can participate in scholarly activity by preparing case report s , literature reviews, practice descriptions, and/ or evaluations.
Reimbursement The question of reimbursement, including third-party payment for ambulatory clinical pharmacy services, has yet to be answered adequately. Currently, selected pharmacists are reimbursed for therapeutic and/or pharmacokinetic consultations either by a separate patient charge or by a fee generated within the practice that is included as part of the physician's fee or office visit. There may also be a fee for establishing a chart and obtaining a medication history when enrolling as a patient in the practice. Other examples of reimbursable services in selected practices include blood pressure checks, compliance counseling, chronic medication management, and patient education. Ambulatory clinical pharmacy services both in the academic and private sectors will continue to expand and vary in scope. Some pharmacists in the family medicine setting provide patient monitoring services and/or direct patient care functions while others primarily serve as pharmacotherapeutic consultants. Clinical pharmacy referral clinics and shared clinical pharmacy services by two or more group practices have been established. Pharmacist involvement in a family medicine setting has generally been perceived as beneficial by the pharmacist, physician, nurse, and patient, and should ultimately result in improved health care. D
References 1. K. L. Me lma n, Nt"ll' Ellxlalld jOlinIal of Mt'dicillt', 284 , 1361 (1971) . 2. K. Steel, t't al. , New Ellxla lld jOlinIal of Medicillc, 304 , 638 (1981). 3. F. T. Stritte r a nd R. M. Bake r, jOllnwl of Mcdical Edl/ catiOIl , 57, 33 (1982) . 4. D . K. Helling, Oms Illtellixt.'llce alld Clillical Pharlllacy , 16, 35 (1982). 5. B. M. Eiche lberge r, American journal of Hospital Pharmacy , 37, 740 (1980). 6. C . P. Reid , E. D. Sumne r, and C. W. Wea rt, pa pe r in pre pa ration.
31