Community Pharmacists as Patient Advocates: Physician Attitudes Susan J. Bradshaw and William R. Doucette
Objectives: To assess physician attitudes toward community pharmacists acting as patient advocates with respect to drug-related; matters, and to correlate physician attitudes with physician characteristics and physician-pharmacist interactions. Setting: State of Utah. Participants: Physicians in family practice, internal medicine, pediatrics, and psychiatry. Interventions: Mail survey. Main
Outcome Measures: Physician attitudes toward community pharmacists performing 15 patient advocacy activities, as well as physi· cian-pharmacist interaction and respondent demographics. Results: Favorable attitudes were identified for pharmacists monitoring drug use, counseling patients, advising physicians, contacting physicians to discuss patients' pharmacotherapy, and recording over· the-counter product use in patient profiles. Attitudes were less favorable toward pharmacists helping patients manage adverse drug reactions, suggesting drug regimen alterations, providing health screening services, selecting drugs by a protocol, discussing thera· peutic equivalents with patients, and changing dosage forms to better suit patient needs. Physician age was negatively correlated with attitude toward a pharmacist aiding a physician in selecting a drug to be prescribed. The helpfulness of physician-pharmacist interac· . tions was positively correlated with physician attitudes. Conclusion: From the physician's perspective, the most appropriate areas for expansion of the community pharmacist's role into patient advocacy are in monitoring pharmacotherapy, assisting physicians in coor· dinating pharmacotherapy, and providing patients with medication information. Physician resistance is more likely in areas where community pharmacists assume a more autonomous role in patient care.
JAm Pharm Assoc. 1998;38:598-602.
Over the past decade, pharmacotherapy has become more complex, with increasingly potent agents and more complicated regimens. To manage chronic diseases, patients must take potent drugs for years, often with limited monitoring. Such a situation is believed to contribute to a significant level of morbidity associated with pharmacotherapy.l Pharmacists have been identified as potential allies for patients in safely managing their pharmacotherapy.2 One role described is that of patient advocate. 3 As advocates, community pharmacists counsel patients about their pharmacotherapy and work with prescribers to refine and individualize regimens to meet patients' specific needs. By helping patients assess the risks and benefits of their pharmacotherapy, pharma-
Received June 30,1997, and in revised form October 10, 1997. Accepted for publication October 18,1997. Susan J. Bradshaw, PharmD, is clinical pharmacy specialist, Medical University of South Carolina. William R. Doucette, PhD, is assistant professor, College of Pharmacy, University of Iowa. Correspondence: William R. Doucette, PhD, S518 PHAR, University of Iowa, Iowa City, IA 52242. Fax: (319) 353-5646. E-mail: [email protected]
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cists can enhance therapeutic outcomes, which is consistent with the philosophy of pharmaceutical care. However, if community pharmacists are to be effective patient advocates, physician support is crucial. The reactions and attitudes of physicians could either hinder or facilitate such an expansion of the community pharmacist's role. Negative attitudes on the part of physicians would tend to discourage their consultation with pharmacists about issues such as alternative drug therapies and dosage adjustments. Conversely, physician support could lend further credibility to the patient advocacy role for community pharmacists by physicians encouraging patients to seek counsel from their pharmacists and proactively working with pharmacists to resolve patients' pharmacotherapy problems. Several studies have addressed physician attitudes toward an expanded role for the community pharmacist, usually in terms of clinical services. 4-9 Generally, physicians support pharmacists' providing drug information, managing minor illness, reporting adverse drug reactions, and advising general practitioners on drug-related issues. Conversely, these studies showed little physician support for pharmacists performing screening activities, making dosage adjustments, or prescribing medications. Ritchey and Raney posited that
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phys icians' attitudes reflect their interests in maintaining task-role boundaries between pharmacists and physicians.8 Physicians' evaluations of pharmacists ' expanded roles have varied on the basis of age and practice specialty. Younger physicians were more favorable toward pharmacists performing patient management tasks.8 Physicians in specialties where malpractice suits are a greater threat (e.g., neurosurgery) were less supportive of expanded roles for pharmacists. 8 A third variable is the nature of physician-pharmacist interactions. In previous studies, physicians who had worked more closely and/or more often with pharmacists were more likely to endorse an expanded role for the pharmacist. 5,9 Given these previous findings, we wanted to better understand physician attitudes toward community pharmacists as patient advocates. This study focused on physician attitudes about pharmacists performing patient advocacy activities, such as discussing therapeutic alternatives with patients. Rather than examining attitudes only about pharmacist clinical decision making, we also were concerned with pharmacists assisting consumer decision making.
Objectives The objectives for this study were to (1) assess physician attitudes toward community pharmacists acting as patient advocates with respect to drug-related matters; and (2) correlate physician attitudes with physician characteristics and physician-pharmacist interactions.
Methods This study used a pretested mail survey to assess physician attitudes toward community pharmacists performing patient advocacyactivities. Fifteen pharmacist activities were described to operationalize the concept of a patient advocate, as conceptualized by Schulz and Brushwood. 3 The content validity of the activities representi ng the patient advocacy role was assessed by three researchers with backgrounds in community pharmacy practice who used our description of patient advocate as a guide. Their I evaluations confirmed that the activities described in the survey represented a patient advocacy role in a community pharmacy setting. For each activity, physician attitudes were assessed using a seven-point Likert scale (l = strongly disagree/7 = strongly agree). The questionnaire incorporated three measures of physician\ pharmacist interactions adopted from Ritchey and Raney,9 assessed on five-point scales: • Frequency of professional interaction with pharmacists (1 = very infrequently/5 = very frequently) • Helpfulness of interactions with pharmacists (I = not at all helpfuV5 = extremely helpful)
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Amount of collaboration with pharmacists (I = no collaboration! 5 = total collaboration). Demographic data included respondents ' ages; practice specialty (family practice, internal medicine, pediatrics, psychiatry, other); practice setting (private practice, group practice, managed care); and practice location (rural, suburban, urban). A systematic random sample of 520 Utah physicians was drawn using the 1995 Directory of Physicians in the United States. We limited the sample to Utah physicians in an attempt to enhance the response rate, since the survey was mailed from the University of Utah. The Directory listed 977 physicians in the four areas of practice sampled: pediatricians, family practitioners, internal medicine physicians, and psychiatrists. These physician groups have frequent professional interaction with community pharmacists, and could influence the latter' s expansion into a patient advocacy role. Retired and nonpracticing physicians were excluded from the study population. Frequencies for physician characteristic data were determined. Means and standard deviations for the attitude rating for each activity were calculated. Correlations between attitude ratings and physician age and measures of physician-pharmacist interactions were computed. Significance levels for correlations were set at p ~ 0 .05 . Data were analyzed using SPSS PC+ version 5.0.
Results Of 520 surveys mailed, 209 usable surveys were returned, with 41 surveys nondeliverable, yielding a response rate of 43.6%. Table I summarizes respondents' characteristics. More than onehalf of the respondents were in internal medicine or family practice. Overall, 59% reported group practice as their primary practice setting. Location of practice was described as urban by 62%, with only 9% practicing in rural locations in Utah. Average age was 45 years.
Table 1. Characteristics of Respondents Practice Area (n = 205*) Interna l medicine Fami ly practice Pediatrics Psych iatry Other
65 53 37 25 25
32 26 18 12 12
S ett ing (n = 203*) Group practice Private practice Man aged ca re
119 62 22
59 30 11
Location (n = 204*) U rban Suburba n Rural
127 59 18
62 29 9
*To t a ls do not equal 209 because of mi SS ing data .
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Table 2. Physician Attitudes toward Patient Advocacy Activities for Community Pharmacists Mean*
Monitoring drug utilization (e.g ., overuse, noncompliance)
Assisting patients in using the prescription drug benefit of their health insurance
Contacting a physician to discuss adjustments in a patient's pharmacotherapy
Including over-the-counter products in patient drug profiles
Discussing noncompliance issues with a patient Providing a patient with accurate medication information, including drug-related risks and benefits
Counseling a patient on medication use
Referring a patient to a physician
Aiding a physician in selecting the drug to be prescribed
Advising a patient on how to manage drug side effects
Suggesting drug regimen alterations to fit a patient's specific life circumstances
Providing health screening services (e.g., cholesterol, blood pressure)
Selecting drugs by a protocol developed with a physician
Discussing therapeutic alternatives with a patient
Changing dosage forms of physician-prescribed drugs to better suit patient needs
*Scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = slightly disagree, 4 = neutral, 5 SD = Standard deviation.
Table 2 shows mean ratings of physician attitudes toward community pharmacists performing patient advocacy activities . Although there was considerable variability in attitude scores, physicians were considered to hold favorable attitudes toward nine activities, which had average ratings greater than 5.00 (5 = slightly agree). Activities with the most favorable mean attitude ratings were: monitoring drug utilization (6.45), assisting patients in using the drug benefit of their health insurance (6.26), contacting a physician to discuss adjustments in a patient' s pharmacotherapy (6.23), and including over-the counter (OTC) products in patient drug profiles (6.23). Six activities did not receive favorable attitude ratings, with mean ratings below 5.00. The least favorable attitude ratings were assigned to changing dosage forms of physician-prescribed drugs to better suit patient needs (3.34), discussing therapeutic alternatives with a patient (3.35), selecting drugs by a protocol developed with a. physician (3.79) , and providing health screening services (4.26) . As indicated in Table 3, physician age showed a significant (negative) correlation with only one attitude rating: aiding a physician in selecting a drug to be prescribed. No significant correlations were found between the frequency of physician pharmacist interaction and the attitude ratings. In contrast, helpfulness of physician-pharmacist interactions demonstrated significant positive correlations with 12 of the 15 patient advocacy activities. Level of physician-pharmacist collaboration had significant positive correlations with four activities.
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= slightly agree, 6
= somewhat agree, 7
Discussion Our results suggest that physicians would support an extensi! of the community pharmacist's role to include some patient adv cacy activities. Overall, physician attitudes toward this new 10 for pharmacists were positive, although certain activities receiv! low ratings. Physicians responded most favorably to activities in whichU pharmacist helps to coordinate therapy, through functions such; monitoring drug use and contacting physicians to discuss adjm ments in pharmacotherapy. Another favorable activity was incl~ ing over-the-counter products in patient drug profiles, suggestifl that physicians recognize the ability of pharmacists to provide relatively complete picture of a patient' s pharmacotherapy. Furthermore, physicians tended to favor those activities i which pharmacists have established a presence, such as counse ing patients on medication use and assisting patients with pn scription drug benefits of health insurance. These findings ar consistent with earlier work on physicians ' attitudes toward a expanded role for pharmacists. 5-8 An exception to these favorabl attitudes was "discussing therapeutic alternatives with a patient Perhaps physicians believe such an activity would interfere wil future product selection or with a patient's willingness to adher to an ongoing therapy. Physician attitudes were least favorable toward communi! pharmacists making independent decisions about drug therapil' such as changing drug dosage forms or selecting drugs by a pJ1)l( col. This finding is consistent with previous studies that reportl physicians ' reluctance to have pharmacists act autonomo usl
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Table 3. Correlations of Physician Attitudes with Years in Practice and Measures of Physician- Pharmacist Interactions Correlation Coefficients Pha rmacist Activity
Physi c ian Ag e
H e lpfulness of Interactions
Level of Collaboration
Advisi ng a patient on how to manage drug side effects
Counseling a patient on medication use
0 . 16
0 . 18
0 . 10
Selecting a drug by a protoco l d e veloped with a physician
Frequency of Interactions
Discuss i ng noncompliance issues with a patient
0 . 14
suggesting drug regimen alterations to fit a patient's specific life circumstances
- 0 .06
0 .24 *
0 .0 8
Including o ver-the-counter products in patient drug profi les
Providing a patient with acc urate medication information, including drug-related risks and ben efit s
0 .37 *
Provid ing health screeni n g services (e .g., cholest e rol, blood pressure)
Discussing thera peutic a lternativ es with a patient
Aiding a physiCian in selecting th e drug to be presc ribed
- 0.20 *
0 .31 *
0 .22 *
Monitoring drug utilization (e .g ., overuse, noncompliance)
Refe rring a patient to a physician
0 . 12
Contacting a physiCian to discuss adjustme nts in a patient's pharmacotherapy
Chang ing dosage form s of physician-prescribed drugs to better suit patient n eeds
ASSisting patients to use th e drug benefit of their health insurance
'Signific ant at p < 0.05.
regarding the rapeutic choices. 5. 8 Apparently, some physicians believe that these activities challenge their autonomy and authority, or possibly interfere with the physician- patient relationship. Physician age was negatively associated with aiding a physician in selecting the drug to be prescribed . Thi s suggests that younger physic ians would be more open to consulting with a pharmacist during the prescribing process. Because of greater interdisciplinary training in recent times, perhaps younger physicians have b een socialized to involve other parties (e.g., pharmacists) in their product selection decisions, while older physicians have been less so . Alternatively, more experienced physicians may feel less need of advice on selecting a drug to prescribe.
limitations Only Utah physicians were surveyed. It is possible that physicians in other states have different attitudes because of practice Variations and cultural differences . Further research is needed to determine w he ther our findings are reflective of the attitudes of phYSicians in general.
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The data reported he re show physician attit udes at a given time. It is feasib le, even likely, that such attitudes w ill change over ti me . A longitudinal examinat io n of physic ian attitudes toward pharmacists could provide insight into the formation of these attitudes.
Future Research Future research should include pharmacist and consumer evaluations of the patient advocacy role for the community pharmacist. If this role is to be successfully adopted, consumers must value pharmacists' contributions to drug therapy, and they must feel comfortable with their inte rac tions with pharmaci s ts and with their pharmacist' s interac tions with thei r physician . Similarl y, pharmacists themselves must recognize the need for a patient advocate in the community setting and wish to assume these activities. A crucial issue is a pharmacist's ability to be a patient advocate-for example, current workloads preclude many pharm acists from performing additional tasks. Research is needed to examine the influence of pharmaci sts' workload and job design
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on their ability to undertake patient advocacy activities. Future research is also needed to gain a greater understanding of physician-pharmacist relations. Pharmacists in institutions have worked hard over the past decades to achieve recognition as a valuable member of the health care team. Community phannacists, too, need to be recognized as peers by physicians. In this respect, the rarity of regular, face-to-face interactions with physicians and other health care practitioners presents a considerable obstacle to role expansion. Understanding this issue and identifying possible strategies for addressing it should be a priority for future research.
Conclusion Ambulatory patients often develop their own medication practices without the assistance of a health care provider. Under these circumstances, the role of patient advocate is a reasonable one for community pharmacists, based on their expertise and accessibility. Our results show that, in general, physicians support this role. The overall pattern of our results indicates that, from the physician's perspective, the greatest opportunities for community pharmacists as patient advocates are in the areas of monitoring pharmacotherapy, assisting the physician in coordinating pharmacotherapy, and pro-
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viding patients with medication information. Increased physicii resistance can be expected in areas where the pharmacist assume, more autonomous role in patient care.
References 1. Johnson JA, Bootman JL. Drug-related morbidity and mortality cost-of-iliness model. Arch Intern Med. 1995;155:1949-56. 2. Lipton HL, Byrns PJ, Soumerai SB, et al. Pharmacists as agents change for rational drug therapy. Int J Tech Assess in Health W, 1995; 11 :485-508. 3. Schulz RM, Brushwood DB. The pharmacist's role in patient care. Ha: ings Center Report. 1991;21:12-7. 4. Bailie GR, Romeo B. New York state primary care physicians' attitu~ to community pharmacists' clinical services . Arch Intern Me. 1996;156:1437-41 . 5. Adamcik BA. Ransford HE, Oppenheimer PR, et al. New clinical roli for pharmacists: a study of role expansion. Soc Sci Med. 1986;23:11 ~ 200. 6. Spencer JA, Edwards C. Pharmacy beyond the dispensary: geneli practitioners' views. 8MJ. 1992;304:1670-2. 7. Ritchey FJ, Raney MR. Physicians' opinions of expanded clinical phi macy services. Am J Public Health. 1983;73,1:96-101 . 8. Ritchey FJ, Raney MR. Medical role-task boundary maintenan ~ physicians' opinions on clinical pharmacy. Med Care. 1981;19: 90-102 9. Ritchey FJ, Raney MR. Effect of exposure on physicians' attitud: toward clinical pharmacists. Am J Hosp Pharm. 1981;38:1459-tl3.
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