Can You Really Trust Your Pharmacist For Health Advice?

Pharmacists have fought for a greater role in providing health care, but as Deakin University's Michael Vagg explains, that can create a conflict of interest.

Pharmacy picture from Shutterstock

Pharmacists are consistently held up as among the most respected and trusted of professionals. They fulfil an important role within the health professions of being the gatekeepers of medication dispensing and the link between the community and their medication use. For more than one hundred years, there has been a very clear and ethical distinction between doctors (who prescribe medications) and pharmacists (who sell them). That way, the argument goes, doctors have no direct financial interest in drugs they prescribe, and pharmacists have no direct financial interest in recommending any of the drugs on their shelves directly to patients. So far, so good.

There has been a bit of role creep over the years, with calls from some doctors to be allowed to sell their own concoctions directly to their patients, as well as a much more concerted push by pharmacists to play a bigger role in health care, including providing immunisations and health checks direct to consumers. Naturally this is of concern to GPs as such proposals have the potential to fragment primary care even further. Not to mention taking the critical role of diagnosis and putting it into the hands of those who are underqualified, underinsured and undersupported to handle it.

What concerns me particularly is not so much that these health checks will take work away from GPs. If anything I suspect they will increase GPs workloads, sorting out the advice already given to patients by wannabe GP enthusiasts like pharmacists and their associated naturopaths. This month's Skeptic magazine from Australian Skeptics highlights the problem quite well.

I think it's time for pharmacists to decide if they want to keep the trust placed in them by the community to give sound advice. If they want to remain a trusted source of advice they need to lift their game and get all the ear candles, homeopathy, magnets, herbs and supplements out of their shops, along with the iridologists and other fairground 'health professionals'. In short, they need to start acting like they deserve the trust and respect that is accorded them. We have heard nothing of the training and CPD requirements for pharmacists who want to diagnose and treat patients, let alone how they will be insured. I would want to see all this detail before I let my croupy baby or breathless grandmother within a bull's roar of a pharmacist's diagnostic skills.

The protectionism involved in the business of running pharmacies is breathtaking. Like dentists, only pharmacists are legally allowed to profit from running pharmacies, and they have defended this with all the bitterness and vitriol you might expect from a group who know they are onto a good thing. Health Minister Peter Dutton seems all for the pharmacists' ambitions and has been on the media trail vowing not to wind back their protected status.

So it seems the pharmacists will have all they want. I wonder if they deserve it? I hope they take the opportunity to lift their game as a profession and use their protected status to raise standards, not profits. A good place to start would be to stop advertising and selling shonky devices and products that would be considered fraudulent in any other context. Too hard? Then get out of the expanded responsibility game for good.The Conversation

Michael Vagg is Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist at Barwon Health. He does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.

This article was originally published on The Conversation. Read the original article.


Comments

    Health advice from pharmacist? No, of course not. They aren't qualified health practitioners and should stick to dispensing medicines and selling over the counter products.

      Except that Pharmacists ARE qualified health professionals, and know things such as
      - current breaking trends in drugs (e.g. "oh, that doctor always prescribes that, it was clinically shown as ineffective about 20 years ago, you should try this")
      - side effects (mixing medications and medication/vitamin mixes)
      - other side effects (holy crap, your doctor is incompetent, her should never have prescribed that as you're clearly pregnant)

      These days they can even take your blood pressure and give you flu shots.
      The wait to see a pharmacist is also generally a lot shorter, and you likely wont need to pay.

    I disagree. I actually work in a pharmacy as a pharmacy assistant. While a pharmacy may sell products like "ear candles" and "herbs", these items are very rarely suggested to a customer. We try to always suggest items that are proven to work (preferably by scientific evidence, if not reviews from employees or other customers which have used the item). We always try to be of help, but will always suggest that the customer goes to see a doctor. In the example of the "croupy baby and breathless grandmother", we would suggest that you go to see a doctor but may suggest an item that could help with symptoms, not a diagnosis. As a biomedical science student as well, I know that various vitamins are pseudoscience, but sometimes that's what the customer wants and they cannot be talked into a more effective product. With doctor's over prescribing antibiotics and statins, maybe pharmacists suggesting alternative therapies is not such a bad thing.

      While a pharmacy may sell products like "ear candles" and "herbs", these items are very rarely suggested to a customer.

      Rarely??? Rubbish like this should never be suggested.

      My concern is much less about selling snake oil - as you say, some people just really want it and will go elsewhere if you don't sell it - but rather about kickbacks from referral systems such as some 'medication reminder' apps where you get a referral code from the pharmacy. These schemes clearly incentivise the pharmacy to recommend these tools, and these tools are money-making devices.
      When there are kickbacks involved in recommending any service or product, then there is a risk of compromising objectivity. In some cases, I would say 'risk' understates is.

      Of course, that isn't to say that all pharmacies engage in such things, and certainly not to suggest doctors aren't similarly compromised by all the free stuff they get from drug companies.

      I managed the front of shop of a pharmacy for about 3 years in my early 20s and agree with macattack. The pharmacist who owned the store I worked at was very anti-vitamins (for 99% of cases) and herbs, etc, however customers would come in looking for them and wanting to buy them. If we didn't sell them, they would get them elsewhere. The pharmacist would always encourage us to ask the customer what they were trying to treat and talk them out of buying the ingredients for "very expensive urine" whenever possible.

    "doctors have no direct financial interest in drugs they prescribe"

    Hahahaha

      Doctors don't have any *direct* financial interest in drugs they prescribe. They do not get a commission of some kind by prescribing them, nor is there some kind of record kept.

      You could argue that them prescribing the drugs puts money back into the health system which ultimately can end up in their pocket, but that's a far cry from being a "direct" interest.

        MA was likely referring to the wining and dining (and other barely legal bribery) the pharmaceutical companies are known to give doctors.

          Traditionally yes, however in more recent times, pharmaceutical companies aren't even allowed to give out pens with the drug name on it.

            They still can give out 'education' evenings at 5 star restaurants and hotels with flights from where ever included...who wants a pen now?

    This entire article reads like it was written by the AMA. (ie. the doctors lobby group)

    On the one sensible sentence in the whole article: " If they want to remain a trusted source of advice they need to lift their game and get all the ear candles, homeopathy, magnets, herbs and supplements out of their shops, along with the iridologists and other fairground ‘health professionals’. " - I couldn't agree more.

    However, in the past five years I have only ever visited a GP once for advice. Every other time it was to convince them to write the script that I need to get the drugs that I already know I need to fix the straightforward ailment I have. When you talk about protectionism, the AMA is the height of it.

    Any doctor who charges above the medicare bulk billing rate has no moral right to take a stand on pharmacists creeping into their easy business. FFS you chose medical science because you wanted to fix sick people. If you'd been in it for the money, you should've studied law.

      Every other time it was to convince them to write the script that I need to get the drugs that I already know I need to fix the straightforward ailment I have. When you talk about protectionism, the AMA is the height of it.
      Endone for your sciatica? :p

        And some Ritalin so I can concentrate ;). ... But seriously, does it take 4 years of medical school to approve doxycycline for every individual trip to Thailand?

          It certainly sounds like you have a chip on your shoulder in regards to doctors. It may be the case you have been exposed to some incompetent ones that have helped form your opinions - but to call medicine "easy business" is complete garbage - I seriously doubt you have any idea what you are talking about when it comes to the difficulty of medicine.
          I can't defend the doctor who seemed to stand in your way of getting doxycycline for your Thailand trip - but what 4 years of medical school does help with is being able to safely utilise the vast amount of information on the internet almost everyone has access to.

            Personally, I'd prefer to see doctor responsibilities shifted to pharmacists in more ways. The only times I've had to see a GP in the last few years are for a couple pretty obvious cases of lung infection or severe head-cold, because work wanted a medical certificate for any absences over one day.

            Besides the pain in the ass of dragging your sick self out of bed (where you probably should be, and where the GP will inevitably TELL YOU you should be) to sit in a waiting room for half an hour past your scheduled appointment, it's kind of an insult, paying $70 bucks for the privilege of being told what you already know, only it's 'official'. Because good luck trying to book a GP visit for a bulk-billing doctor anywhere inside of 5 days notice, or hell... even FIND one who will agree to bulk bill anywhere inside major city limits without a low-income health care card.

            You should never attribute to malice or greed what can be explained by incompetence, but it's hard to see why these complaints haven't been resolved yet by the market without someone somewhere dictating 'how it has to be'.

              I had to get a doctors certificate for having one day off work last week. I was way too sick to get out of bed (migraine) let alone drive to the doctors, and I couldn't ask anyone else to drive me because they were at work, so I went the following day when I just had a nice little migraine-hangover floating around. I knew I didn't look sick, because well.. I wasn't really sick any more. I was basically just wasting the doctors time convincing him I needed a certificate. $78 for the pleasure, too.

              TL;DR - I'd love to see pharmacists able to give out doctors certs.

                bulk billing locum services exist in all capital cities...

                Not sure where you are, but they're allowed to in WA.

              The requirement for a sick certificate has little to do with the profession and everything to do with your particular workplace agreement/award. In the case of your "obvious case" examples, both of those may have been obvious at the time and ended up that way, but plenty do in fact require thought, experience and training to ensure there's nothing more to it. The subsequent management is also a challenge and needs a professional to figure it out. Being an armchair "Dr Google" is laughable and the kind of hubris that leads people to the hospital eventually.

    Pharmacists know more about how different drugs react in your body and can veto the doctor by considering what you're currently taking anyway. The person behind the counter you talk to probably isn't a pharmacist, most likely a student or casual employee. They will take your script and give it to the pharmacists who is licensed to dispense. If you want to talk to the pharmacists you have to ask. As for the homeopathy stuff, it sells and is profitable.

      So do many other things that violate section 52 of the trade practices act. It's not a general store, pharmacies should be bound to carry only products scientifically proven to work better than a placebo. Especially if they want the right to prescribe too.

        I think there is a risk of conflating 'proven not to work' with 'not proven to work'. Obviously, 'proven to work' is better, but there is a difference between these other two. For example, testing of homeopathic remedies have demonstrated a lack of efficacy. However, there are some herbs for which there are actual indications they may have an effect but they have been inadequately tested to be sure. (One example is a couple of adjunct compounds which can be taken to try to reduce prostate inflammation, but I can't remember what it is called - my father uses it, so I looked it up). There is preliminary evidence of possible efficacy, but there simply hasn't been enough testing to know for sure.

        This was the case until not terribly long ago for St. John's Wort. We now know that it is efficacious for treating mild depressive symptoms (although variability in active ingredient concentration in what is sold is a problem), but that required quite a lot of testing which has only fairly recently been done.

        Basically, what I'm saying is that although it is a big bodgy for pharmacies to be selling stuff which has been demonstrated not to work, it may be a bridge too far to only sell things which we are absolutely certain are effective.

          @vj9c9 I do agree with you, but it's a slippery slope.

          A homeopathic fanatic would say that homeopathy has not been proven not to work... (in fact the science says it does: just google for "efficacy of placebo" to see the results) only that there hasn't been a scientific study yet that proves it works better than a placebo, but who trusts science anyway, they're bias.

          Pharmacies sell lots of herbal compounds which have been proven to work, and carry a "R Number" from the ARTG. But if they want to gain the respect of the medical industry and start prescribing as well as vetting and administering medicines (which I think they should, because it really shouldn't need 4 years of medical school to prescribe antibiotics for sinusitis in an otherwise healthy adult) - they should do a lot more to educate their customers when they purchase something that's not proven to assist.

          I do think that if pharmacies carry herbal remedies that only carry a "L Number" (proven to be safe but not proven to work) , they should be highlighting the differences to customers. If they do make the distinction to customers, I don't see a huge problem with this.

          However, as long as pharmacies carry homeopathic remedies - which have been subjected to considerable scientific testing and not shown any positive results - on the grounds that 'people ask for them and they're very profitable' - I don't think they should expect to see any increases in their medical decision-making authority, because it's evidence that they (or their employers) put profits ahead of good science.

            Sorry, when I said 'proven not to work', I meant 'proven to have no incremental benefit over placebo'.
            I absolutely agree with you about remedies that only have an L number. It is an annoyingly fuzzy area because it is hard to separate the 'not adequately tested but some positive indicators' from 'not adequately tested and no real indicators of benefit yet'. Worse still, depending on the way that positive and negative tentative finding are communicated to consumers there can be an incentive to not do testing in case results come back negative.

            It's a messy area: especially when you then add in results withheld by pharma companies such as discussed by Ben Goldacre here it gets even messier.

      I agree pharmacists will have studied the literature and evidence behind the medicines they give - however this does not equate with having experience in using them in humans day to day and SEEING the effects in vivo. If pharmacists want more responsibility when it comes to diagnosis and management then they will need to know how to fix things when it all goes wrong. "Diagnose" high blood pressure on the pharmacy BP machine? Lets say the pharmacist starts a medication and it doesn't work, will the pharmacist manage the kidney impairment if it happens? Will they search for causes that will need more than a tablet to fix? They can't pick and choose what they want to handle - it is dangerous fragmentation of care.
      I don't even need to discuss homeopathy in detail (sensible people should be able to make the right decision themselves on that). The fact that it sells and is profitable despite having a glaring lack of CREDIBLE supporting evidence does nothing to help the aspiring "pharmacist/doctor" to be taken seriously.

        While in the past pharmacies were independently owned, watering down of the ownership parts of the law has allowed large chains to emerge where the owner doesn't work in the store. Simply put the pharmacist on duty doesn't have any say over what is in the store most of the time, and has this has also driven down pharmacist wages.

        What you should be really concerned about is the plan for the large supermarkets to employ people to offer health checks.

    I avoid going to the chemist as much as possible. The Pharmacy Assistants these days seem to think that they are social workers and masters in medicine. I just want what my doctor has ordered for my ailment - not a lecture from some lifestyle guru in earshot of all and sundry!

    Well maybe if the public are willing to pay for their drugs then the pharmacy can stop selling "ear candles" and "herbs" and concentrate on providing the right advice for the dispensed drugs. A pharmacy is a business as well (just like a doctors surgery); it needs to make money. The only way the local pharmacy can stay afloat is to sell all the other rubbish because the public are not willing or able to pay the true market price for their drugs.
    The public is unaware how much subsidies they get on their drugs which is always getting reduce year after year, yet the pharmacy are unable to increase their prices because customers complain, get agressive or be just plain rude about it.
    When we buy our drugs we are also paying for their service (which is also their legal obligation) to ensure we take the drugs correctly, be aware of side effects and if the drug has been correctly prescribe to you. That is why you get asked 20 questions about your health & lifestyle.

    To start with, id like to say that I am not writing this in an attempt to retaliate or incite a conflict about views that have been expressed in the comments so far. All I would like to do is share a different point of view in the hope that some understanding can be shared.

    I am a Victorian final year student of a post-graduate medical degree and there are a few points I would like to address. I feel I am in a good position to explain a few things because I feel as though I am somewhat ‘in limbo’ between being a member of the wider community while also only just entering the medical community.

    Firstly, it takes far longer than 4 years to get to a point of prescribing to the public in a general practice setting. here is a brief breakdown for a post graduate medical course: 3-4 years in an undergraduate degree -> 4 years postgraduate medical degree -> 1 year internship in a hospital -> 1+ years as a resident in a hospital -> 3-4 years in GP training program. So it actually takes more like 10+ years as a bare minimum to get to the point xqx refers to.

    Secondly, the waiting times and appointment availability are not purely the fault/responsibility of individual GP practices. There is a shortage of GPs in general so of course there are going to be significant waiting times. But there are more GPs coming, they just need to be trained! It’s more a political issue than anything a GP can do individually.

    Thirdly, the GP being utilised to diagnose a ‘simple problem such as a lung infection’ is, I believe, a little unfair. Having spent time sitting in on consultations with fantastic GPs I can now see that the entire time a consult is occurring, a GP is continually assessing the patient’s actions and asking specific questions that are attempting to rule out the more serious conditions that pose a threat to a patient. Admittedly, most illnesses that present are fairly straight forward, and this is a good thing, but it would be terrible to miss that one patient who has a life-threatening illness in its early stages, because the right questions were not asked, or the proper examination not performed.

    These are just a few of the issues that I often hear about with regards to doctors that I believe are caused by misunderstandings on both sides of the argument. I guess I just wanted to get a different point of view out there so that people might feel less frustration and maybe see things from a different view.

    TL;DR: Medicine takes ages to do, GPs are very cool, sometimes it’s a good thing to only be in the doctors rooms for a short time!

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