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How best to use clinical knowledge in practice

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By Matt Yates
7 Jul 2011

 We all look at the BNF with fear, wondering how we will ever remember all those different drug doses, interactions and directions for use. It is very humbling, making us realise how far we have to go before we are pharmacists.

 This is why, when I started my Summer Placement this summer, I was anxious to observe the pharmacist clinically checking prescriptions.

It seems to be so effortless, the pharmacist seemingly skim-reading the prescription. In my time on placement, I have not observed the pharmacist making a single intervention.

This made me think : Is the clinical knowledge of the community pharmacist being put to best use, or is the doctors' prescribing really faultless?

 I watched with concern as the pharmacist declared a prescription to be clinically safe, despite severe interaction warnings on the Patient Medication Record. Is this a sign that pharmacists learn extensively about interactions, but in reality, pay no attention to them?

On the other hand, on a hospital placement, I frequently observed pharmacists annotating drug charts, making recommendations and endorsements, and questioning doses etc. I know that hospital patients may well be more acutely ill, but is this a sign that hospital pharmacists are using more clinical knowledge, or that because of the chronic nature of conditions seen in community pharmacy, a more laissez-faire approach is adopted?

After all, we all want to use our clinical knowledge, and we will ultimately choose the setting that best allows us to do this.

Clinical knowledge on the high street

Hello Matt,

Thanks for a great post.

The type and scope of clinical intervention in community pharmacy practice is different from the clinical intervention in hospital (I should know: I work partly in the community and partly in the hospital). I cannot speak for the community pharmacist you observed but I am able to tell you that the community pharmacists are clinicians on the high street (http://www.pjonline.com/blog/the_high_street_clinician) and must practice as such. The blog I write is a reflection on my practice as a community pharmacist.

Limitation of information is not an excuse for not applying our clinical knowledge whatever the setting.

You cannot let your inability to do everything undermine your determination to do something – Mayor Booker of Newark 

Its all because of cash

Unfortunately many pharmacists do the bare minimum with regards to clinical matters because they just don't have time. This is mainly down to the fact that pharmacies are run to make money, not in the patients' interests. This means that pharmacists are forced to take on as many services as possible with as few staff and as little space as possible and they therefore don't have time to actually do things properly. I've spoken to more than one pharmacist who would consider it "timewasting" to counsel a patient instead of just giving out the medication.

What happens when a pharmacist sees a prescription?

Would you be able to give me like a summary of what you look for when you see a prescription?

An idea of the thought processes of what to check in a prescription would be great!

Tell me if I'm wrong, but I imagine it would be the following :

Dose of drug, age of patient, legality of script, interactions between drugs on script. How much of this clinical checking is done by the pharmacist and how much is actually performed by the PMR?

Many thanks.

Hmm..

 I've spoken to more than one pharmacist who would consider it "timewasting" to counsel a patient instead of just giving out the medication.

Any pharmacist that considers counselling patient as 'timewasting' is not only misguided. They are also wrong and must undergo mandated further training. What is the point of dispensing if you cannot impart the knowledge of how to use the medicine effectively to the patient? The time and money argument, although valid in some instances, is wearing thin and in time, will become untenable. The New Medicines Service (NMS), implemented effectively, should mandate the counselling of every patient who has been prescribed a new medicine.

Matt is right. Some of the checks can be done electronically. They can be done by training support staffs who are generating labels to watch out for computer-generated interactions and changes in doses and strengths. The time gained from an empowered and delegated workforce can be directed to customer facing role. If we don't start to think like that now, we will become irrelevant tomorrow.

On what you actually do when you do a clinical check, the RPS produced a great guide which I highlighted here (http://www.pjonline.com/blog_entry/clinical_decision_making_part_2). I have given examples of the range of intervention you could be doing now (http://www.pjonline.com/blog/the_high_street_clinician): They don't have to be complex. You can always prioritise interventions - I know there are time pressures.

 You cannot let your inability to do everything undermine your determination to do something – Mayor Booker of Newark