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    The Pharmacy Physician Assistant

    An idea whose time has come

    Robert L. MabeeThe disruption of large sectors of the healthcare industry that has occurred since the ACA became law has produced the opportunity and necessity for systemic change. This crisis must not be wasted. Primary care physicians led by family practice doctors must take control of the healthcare system.

    A key element of such a change involves pharmacists. The market is ready for the Pharmacy Physician Assistant (PPA).

    Pharmacists have long been recognized as the most underused element of the primary care team. Their role has expanded already in some underserved portions of the healthcare market. A New York Times editorial, titled “When the doctor is not needed,” published December 15, 2012, commented:

    A report by the chief pharmacist of the United States Public Health Service a year ago argued persuasively that pharmacists are “remarkably underutilized” given their education, training and closeness to the community. The chief exceptions are pharmacists who work in federal agencies like the Dept. of Veterans Affairs, the Dept. of Defense and the Indian Health Service, where they deliver a lot of health care with minimal supervision. After an initial diagnosis is made by a doctor, federal pharmacists manage the care of patients when medications are the primary treatment, as is very often the case.

    With creation of PPAs, the role of the pharmacist can quickly expand to include additional services. Many pharmacists have trained in a variety of specialty areas, including immunization, basic lab testing, and collection of clinical data. Using theses skills, they can serve as an extension of the patient’s primary care doctor.  

    Robert L. Mabee, RPh, JD, MBA
    Robert L. Mabee is a pharmacist and attorney practicing in Sioux Falls, S.D. He also holds an MBA. Contact him at [email protected]

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    • Mr. dmorgan
      Pharmacist practitioners were trained by the Indian Health Service in in the early 1980's in Phoenix for a few years. The training was primarily in diagnostics since that piece is not included in pharmacy school. My brother (now retired) completed this training. I was a CEO in the Indian Health Service at the time and still active in pharmacy activities (being also a pharmacist). Several classes of students were trained. Once trained, the pharmacist practitioner was drawn away from pharmacy operations due to tremendous demand in clinic as a practitioner. This didn't make them very popular with the pharmacists left in the pharmacy who were forced to fill all the prescriptions with one less body on the line. Several positions were created for the pharmacist practitioner from vacant medical staff positions, but this was not very popular with the physicians. As an administrator, I found in much less expensive to hire a physician assistant and avoid the friction created by this new practitioner. I mention this to suggest that the pharmacist practitioner is not needed due to the availability of med level practitioners (PAs, NPs). Several chains are experimenting or prepared to experiment with mid-level practitioners inside their drug stores (eg. Safeway), but use of a pharmacist for this task is not desirable for two reasons. First is the expense mentioned above (compare the salary of pharmacist to the mid-level practioner). Second is the significant lack of diagnostic training in the education of pharmacists. There are clinical roles for the pharmacist in the retail setting, and they focus on the expansion of the medication therapy monitoring of the pharmacist. MTM is a start. Perhaps one goal would be to have pharmacists, after initial diagnosis establish, monitor, and modify medication therapy for certain types of chronic care (EG. diabetes, hypertension, etc). In fact, this is already being done in the Indian Health Service utilizing written guidelines established through the local Medical Staff. I have never understood why pharmacy has not learned more from pharmacist utilization in the Indian Health Service. There are major system issues that need to be resolved for the pharmacist in the retail setting to be fully utilized. Not the least is the lack of interaction between the physician and pharmacist. The ability of the pharmacist's clinical role expansion in the Indian Health Service (and VA) is directly related to the continual face to face interaction between the pharmacist and practitioner. Once this occurs, the pharmacist becomes an asset to the practitioner and working agreements for clinical expansion are much easier. I now work in a busy chain drug store, and I can count on one hand the times that I have had telephonic interaction directly with a practitioner to discuss medication therapy. When I find an ACEI cough (or other medication problem),I find it more effective to give the patient the name of the medication I recommend and have them ask the physician rather than communicate directly to the physician since they are more effective in influencing the medication prescribed. (Why do you think manufacturers spend so much on direct consumer advertising and so little on trying to convince pharmacists). I frequently can't even influence the prescribing habits of a physician assistant - as an example - a young man with severe second degree burns over his entire arm came to the pharmacy from the ER seen by a PA with a prescription for 50 g. of silvadene and pain pills and a referral to a burn clinic 150 miles away in 2-3 days. He had huge blisters from his wrist to his shoulder. No systemic antibiotic, no directions on cleaning the area, and no directions as to how to handle the blisters if they popped (a couple already had). I sent him back to the ER and wrote down "Septra" and "clindamycin" so that we could cover community acquired MRSA which is prevalent in this area, instructed him how to remove the dead skin if the blisters popped, and directed him the the Hibiclens for twice a day scrubbing including removal of the layer that forms over the top of exposed skin if blisters pop. He came back from the ER with a prescription for cephalexin!(does not kill MRSA) All this to say that I believe that the pharmacist in the retail setting is underutilized in medication monitoring through expanded MTM holds some promise. There are many other issues that should be explored such as the type of documentation needed by the pharmadcist, access to the physician generated medical record, legal authority for the pharmacist to order lab tests (imagine how we could impact the over-utilization of narcotic pain meds if the pharmacist could order drug screens and direct changes in therapy according to protocol in response to the results -(by the way something that is also done in the Indian Health Service).
    • Anonymous
      PPA's already exist. They are called Clinical Pharmacy Practitioners (CPP's) and work under a collaborative practice agreement with their physician. Their role is not exactly as described in this article for PPA's but the role could easily be expanded. North Carolina is one state that recognizes CPP's.
    • Anonymous
      It seems like the author of this article is completely out of touch with reality. While the idea of pharmacists being PCPs looks great on paper, in fact it would be a disaster. Just to give an example, we tried to expend our services by offering vaccinations. What happened next? Pharmacists got slapped in the face with a new metric goal from the chains. And yes. People lost their jobs because they could not achieve the imaginary goals. Guess what will happen if we are allowed to provide PCS? We will be slapped with another metric and increased prescription budget goals.
    • Anonymous
      Now, that I've skimmed the article, I can see that it's an idea, merely an idea. Coming up with ideas is a good thing. Frankly, however, basing a scenario on the failure of the ACA, automatically puts the gist into 'conspiracy theory' mode. Whatever it is and and whatever it does, we're in the midst of it and we will make it work. To consider the example of the VA, many safeguards (in the pharmacy, at least) were set in place to provide services in a sophisticated and routine manner to a large group of American citizens who were impoverished to some degree to have to depend solely on this medical care, so their rights to protest any misguided or misdirected management choices, was quashed until evidence of bungling results in deaths. At one time, for sure this was in the 80's, the VA Pharmacy was the cutting edge in providing pharmaceutical care for veterans and the Chief of Pharmacy was equally important as the Chief of Medicine and Chief of Nursing, not a subdivision of the Chief of Materiels Management or Chief of (Human) Maintenance. But, to argue about the VA nowadays is to acknowledge a general lack of due diligence to veteran care mainly from lack of consistent funding of the Dept of Veterans' Affairs. That VA example aside, unless the ACA 'means' that the lack of proper oversight of healthcare funds will hit the skids, there should be no need for a pharmacist assistant, if proper funding for the pharmacist provider is set in place. And, technicians, and under whatsoever guise whoever they are, should not be designated as 'Providers'. Considering the quibbling by State Boards of Pharmacy over how many technicians may work 'under' a pharmacist, I don't think that there is any agreement over what the registered pharmacist can practically do one-to-one. It would seem that there are certain tasks that might be appropriate for technicians, but as for speaking as someone with the authority of a registered pharmacist, that should remain the legal prerogative of one so deemed by society as the pharmacist. Considering viability of a full-fledged pharmacist assistant with legislated duties beyond that of the pharmacist just undercuts the general quality and professionalism of the pharmacist.
    • Anonymous
      I believe that the patient would come to you with the diagnosis for you to manage. There are many conditions I feel very qualified to control. We already have programs showing the value of the pharmacist treating patients and lowering costs. The Ashville Project is one of them.
    • Anonymous
      Comparing pharmacists to PAs? Really? It doesn't matter how many semesters of pcol we had over them, we weren't taught to diagnose. This idea that we need a special title for things we already do is a bit insulting to me. Or is it all about the $$$? If that's the case then get off your lazy rear end and tell your Congressman to amend Medicare reimbursement laws to reflect us as providers. APhA has failed miserably at it.
    • Anonymous
      Pharmacist training includes the ability of the practitioner to work solo, although since the 80's with the designation of the recognized certified pharmacy technician, certain tasks in the pharmacist job description can be legally delegated to technicians. There is a delicate balance, however, in 'acting as a pharmacist' and 'acting for the pharmacist'. Pharmacists rarely own their business for themselves and often are employed in 'package deals' with the registered pharmacist as the token licensed personnel representing society's interest in maintaining some medical 'decorum' in the arena of pharmaceutical knowledge. Take a look at the legislation in states setting to place unlicensed drug dealers as the legal drug experts in pot shops. Take a look at the cabal of government representatives choosing to take their medical prescriptions across the northern border into Canada. Take a look at the wholesale prescription industry provided by the mail-order companies. Already, the pharmacist duty to society has been handed piecemeal out to consumers who have no idea of the ethical obligations of registered pharmacists. Without reading the article, yet, my opinion of physician assistants is a lousy idea, and if pharmacists were not hounded by every pharmacy benefit middleman and allowed to actually 'do' their job, there'd be no talk of this 'assistant' job. Does one seriously consider that pharmacists got into the their 5- and 6-year programs to have their livelihood and exhaustive pharmacy training and (job satisfaction in the periphery somewhere) removed from them by an assistant whose allegiance is to someone somewhere other than the pharmacist? Well, now, I'll read the article and respond afterwards.