E-DRUG: pharmacy drivers, Trust and Ethics

["Andy Gray" <agray@pixie.udw.ac.za>]

E-DRUG: pharmacy drivers, Trust and Ethics (cont)
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Hi all

Mariam  has certainly sparked some interesting debate on the 
issue of "face to face" counselling. While we have veered from trust 
to patient rights, from training of drivers to concordance 
(asyoulikeit - WB will have to teach us to pronounce that with the 
right accent), I think an important dimension has been missed. 

The SA Pharmacy Council (our statutory body) has chosen to use two 
separate mechanisms with which to control the practice of the 
profession. The first can be regarded as the "aspirational" side - a 
series of publications on Good Pharmacy Practice in various settings 
(hospital, community practice etc). The second, a survivor of the 
previous set of Rules which complement the local Pharmacy Act, 
is a dismal listing of possible misdemeanours. The relevant section 
of the Act states that "the council may from time to time make rules 
specifying the acts of omissions in respect of which the council may 
take disciplinary action". Naturally the Council also reserves the 
right to deal with any complaint, charge or allegation and not be 
restricted to those specified in the rules. The Rules in question are 
prefaced by a statement that "the undermentioned acts or omissions 
shall be deemed to be unethical or unprofessional conduct". It would 
therefore seem appropriate that the Good Pharmacy Practice guidelines 
would seek to advance the profession, and would include aspects which 
cannot yet be attained, but which should be aimed for - the "nice to 
have". It would however, clearly distinguish such aspects from the 
minimal standards for safe practice - the "have to have". The 
so-called "Ethical Rules" would then be expected to be clear and 
unambiguous statements of the "have to have", worded in reverse - the 
list of acts of omissions which would be "unethical or unprofessional 
conduct". Let's revisit the wording proposed in the amendment (the 
current wording ends after para (a)):

"Failure in the interest of the patient to:-

(a) furnish advice or information for the safe and effective use of
medicines supplied by him/her.
(b) counsel personally a patient or the person to whom the medicine is
supplied on behalf of the patient on any matter which in the
pharmacist's judgement, will enhance or optimise the medicine therapy
prescribed:

Provided that such counselling should be done face to face."

The first paragraph is the general rule, but does not specify how 
that information is to be furnished. The second is amplified by the 
statement about the "counselling" being done "face to face". When the 
practicality of the situation is questioned, the reply is that such 
counselling is only obligatory when, "in the pharmacist's judgement", 
some information has to be conveyed which "will enhance the medicine 
therapy". 

What I think has been missing from the debate is whether or not this 
is good law, not whether or not counselling is necessary, or who 
should do it. In a perfect world, everyone would be counselled (by 
Billy's standard) whenever receiving medicine. That counselling would 
occur "face to face", so that all non-verbal clues could be detected 
and acted upon. The counselling would also be done by someone 
adequately trained (pharmacist or suitable registered support 
personnel). However, if we go back to Rina's comments, we see that 
there are many situations in pharmacy  where "face to 
face" contact is not possible. Let us imagine that such a situation 
is detected by the Council, and disciplinary action is initiated. 
Would it be sufficient defence for the pharmacist to claim that "in 
his/her judgment" no additional information was required in that 
particular case?

In South Africa, as in many developing countries, we face a shortage 
of trained personnel, as well as maldistribution of those we do have 
(see http://www.hst.org.za/sahr/98/Pharmacy/ for a report produced by the 
Pharmacy Council on this issue). In the public sector post-basic 
trained pharmacists' assistants will practise under indirect 
supervision in primary care settings. In the private sector, the use 
of technology might be the answer. Under the current suggestion, 
would it be unethical for a pharmacist to supply sophisticated 
antibiotics to the Intensive Care Unit without counselling the 
care-giver (nurse, or hospital porter who transports the medicine to 
the ward)? Or would the excuse have to be that no additional 
information was warranted? Would a pharmacist practising in a 
courier-delivery (mail order) system, who had communicated with the 
patient by telephone and in writing, be considered unprofessional? 

I'm not convinced that any disciplinary action based on the suggested 
wording will succeed. But what I do agree with, is that face to face 
counselling should be included in the Good Pharmacy Practice 
guidelines as an aspirational goal. 

South Africa will always be an intriguing mix  - in the public sector 
we have to strive to achieve a minimum standard. As a taster, there 
are currently 15 state hospitals in the Free State province (pop 2.6mill) 
which have no pharmacist at all. In our well-funded fee-for-service 
private sector, we see almost every technological tweak possible. As 
a final teaser - consider the following: in proposing a model for 
for licensing practitioners in Internet-based telemedicine (see
http://www.fsmb.org/telemed.htm), the Federation of State Medical Boards 
of the United States made the following statement:
"Telemedicine demonstration projects have clearly shown that current
technology will allow a physician in a distant state to conduct
"face-to-face" consultations with a patient in another state".

So - a good idea, well backed by theory, evidence and sentiment. But good law? 
I have my doubts. 

regards
Andy

Email: agray@pixie.udw.ac.za [manually added by moderator; WB]
 
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