CODES

In 1994 the profession of pharmacy, spearheaded by APhA and encouraged by the Joint Commission of Pharmacy Practitioners, put forth a new and dramatically different Code of Ethics. The Code is based on the concept of pharmaceutical care as developed by Hepler and Strand.¹ It requires a level of professional practice that carries with it far more responsibilities, yet far more autonomy. Votterro⁸ commented that “Pharmacists who respond to this additional level of professional practice and autonomy and embrace the unique caring expectations of this new practice mode will be further challenged to demonstrate group and personal behavior that may be far beyond the present expectations of society.” The preamble and eight principles of the Code of Ethics for Pharmacists appear above, and the full text of the Code⁹ is available at www.pharmacist.com.

Look at the first principle: “A pharmacist respects the covenantal relationship between the patient and pharmacist.” There is that covenant thing again. Are we serious about this? This is a profoundly important statement. What it requires of the pharmacist is serious business. It requires a commitment on the part of the pharmacist to virtues and existential advocacy. Are we ready? Are we to have a Code in name only—something that is nice but that we really don’t intend to do—or is it time to seriously challenge ourselves and ask, How do we get there? How do we make our Code live? If we are not ready, what steps are needed to get us there?

STANDARDS

To move forward, we must look at standards. What is pharmacy’s standard? What can we promise patients when they walk into a pharmacy to get a prescription filled? Do pharmacists provide verbal counseling for each patient with a new prescription? Do pharmacists provide all patients with written medication information? In both cases, the answer is no. What we generally do provide for each patient is the medication ordered by the physician. We are very good at dispensing exactly what is written on the prescription. Unfortunately, what the physician orders is not always appropriate for the patient.

There are many pharmacists who counsel each patient and not only question the appropriateness of the drug therapy prescribed but also act on the behalf of patients to change the drug therapy when necessary. However, for this to be a standard, it must be done each time, by all pharmacists. That is what a standard of practice is. Why are we surprised that we get paid (and often not well) only for dispensing drugs, when that is our standard? Pharmacists who have raised their standard are getting paid for more than just dispensing.

So, how do we develop standards? One way is to look at what we know. What does research tell us about what must happen to produce positive drug therapy outcomes? We know that in order to achieve optimal outcomes from their drug therapy, patients must

Understand the diagnosis. Do patients understand the diagnosis and treatment? Do they know what they need to do? Do they believe they can do it?

Be interested in their health. Do patients care whether or not they get healthier, and do they want to prevent illness?

Correctly assess the potential impact of the diagnosis. Do patients understand what will happen if they do or do not treat the illness appropriately?

Believe in the efficacy of the prescribed treatment. Do patients believe that the medication will have the intended effect? Do they understand what the medication actually does and how they will know whether it is working?

Find ways of using the medication that are not more trouble than the disease. Some illnesses “feel” better than the treatment. For example, patients with high blood pressure often initially feel worse when they are put on medication. Do they understand that this may happen? Do they know that this is usually transient? Do they know what to do if this condition does not change after a specified period of time? Do patients know how long it should take for the medicine to have its intended effect, what the effect is, and how to measure it, if necessary (e.g., by measuring blood pressure or peak flow)?

Be assessed regarding their readiness. Substantial literature supports variation among patients in readiness to manage their illnesses and the self-management behaviors necessary to manage the illness. Different strategies are necessary for different stages of readiness. Are patients being properly assessed so that appropriate interventions are used?

Patients who meet these criteria are likely to adhere to (comply with) their medication regimens. Therefore, if pharmacists are to have a substantive impact on health outcomes in patients, our standards of practice must include ways of addressing these issues. The way we communicate information to patients is part of our standards. For example, how do we tell patients what “1 bid” means? Do we tell them that this means approximately 12 hours apart and then tailor the dosing times to their daily routine, or do we tell them to take the medicine twice a day and hope they figure out what we mean? What does “1 pc and hs” mean? What does it mean for a patient with diabetes who eats six small meals a day? Do we really want him taking the medicine seven times a day? How we communicate information should be part of our standards, because it affects treatment outcomes.

MAKING THE TRANSITION: SOME ASSUMPTIONS

Before going any further, it is important to state some underlying assumptions:

         Pharmaceutical care is the mission of pharmacy practice. It involves optimizing health outcomes through the appropriate use of pharmacotherapy.

         There is a market need for pharmaceutical care. Pharmacists must create the demand.

         Most pharmacists want to provide pharmaceutical care. Many have a hard time imagining how to do so in an environment that has focused on dispensing drugs.

         Providing pharmaceutical care will lower health care costs in total (or at the very least, raise quality without increasing the total costs of care).

         Great courage is needed by all pharmacists in all work settings to demand that our professional standardss not be compromised. What is courage? It is the will to look for right answers. According to Dixon,⁷ “What brings the right answer is an exercise of justice and realism and really looking. The difficulty is to keep the attention fixed upon the real situation and to prevent focusing on our own needs or defenses.”

         Pharmacists need not fear that they will lose their jobs for upholding the law or raising standards.

         We must stop blaming others for our problems. When people are placed in extraordinary or difficult situations in which they must choose that which is good, right, or moral versus that which is expedient, great courage is needed. Otherwise they must become numb or blame someone or something else in order to escape the pain of giving up what they know is right. Pharmacists, for far too long now, have been placed in those very difficult situations in which they must choose, and too often they have chosen what is expedient. To be courageous is very frightening and often painfully lonely. However, doing what we know at our core is just not right hurts our very souls. That is a much higher price to pay, and it is time for it to stop.

         We must stop believing that anyone other than pharmacists is interested in our survival as a profession.

         The transition will require a concerted effort from many different groups, including pharmacists, schools of pharmacy and their faculty members, pharmacy students, state boards of pharmacy, providers of continuing professional education, and our state and national professional associations.

WHAT PHARMACISTS CAN DO

Let’s start with what pharmacists need to do. First, we must realize that whenever members of a profession allow others to dictate their practice standards, they, in a very real sense, cease to be a profession. Pharmacists must be willing to do the courageous work of standing up and saying that something is terribly wrong when their professional ethics and morals are compromised. What would this mean? It would mean actively counseling patients regardless of how busy you are. It would mean that patients would, at minimum, be assessed to ensure that the medication prescribed is right for them and to make sure they understand their illness and its treatment, and that they would have their questions or concerns addressed (or an appointment would be made to do so).

Impossible, you say. Patients would get backed up. Patients would find another pharmacy to go to because they wouldn’t want to wait. Many would call corporate offices complaining about the long waits. You could get fired. Or, for the first time, patients would see how valuable the pharmacist is and would be willing to wait for and pay for this value (we know that patients consistently say they want and value this from the pharmacist).

Some patients would leave and go where it’s cheap and fast. Some would call corporate offices and complain. What are we afraid of? Do we really believe that someone is going to fire a pharmacist for raising or upholding standards? If a pharmacist did get fired for this, I think the pharmacist would have a case to successfully sue the organization.

Best of all, we, not some external body, would be setting our standards. The danger is, of course, that few would be brave enough to do this. But what a day this would be! Jesse Vivian, a pharmacist and attorney, has said he would welcome the opportunity to defend any pharmacist who is fired for upholding or raising standards.

Start small.

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