More Than Just Pill Counters

Clinically trained pharmacists begin prescribing for patients

Pharmacists have long languished near the bottom of the medical totem pole, contemptuously referred to by doctors and nurses as pill counters. But the term may no longer be justified. As the number of drugs has multiplied and human reactions to them have become more varied, pharmacists are beginning to assume a more important role, counseling patients on medication, monitoring drug therapy and sometimes even prescribing drugs.

Says Pharmacist Jere Goyan of the University of California at San Francisco and former commissioner of the Food and Drug Administration: "It used to be that making the diagnosis was the difficult part, and the idea was that any damn fool could prescribe, especially since there were so few drugs that worked. Now there are so many, and all have some sort of bad effects too." Pharmacists get three to four years of training, almost exclusively about drugs. Many of them know more than doctors do about potentially dangerous drug interactions. Medical schools usually give only one formal course in pharmacology. Physicians, in fact, pick up their practical drug knowledge on the job and by reading the medical journals. A hotly debated but durable criticism of physicians is that they rely heavily on drug-company literature and advertising, both sometimes misleading. Another reason for expanding the pharmacist's duties: doctors are often overworked and in short supply.

One place where pharmacists have been playing an important role is in the Indian Health Service, whose clinics are in remote locations and chronically short staffed. Since 1973, the Phoenix Indian Medical Center has given 65 pharmacists special six-month courses in clinical skills, including how to take a medical history and conduct a physical examination. Working under a doctor's supervision, these "pharmacist practitioners" regularly diagnose and treat skin conditions, burns and abrasions, gastrointestinal upsets and upper-respiratory infections. They monitor therapy on patients with hypertension, tuberculosis and diabetes and also provide prenatal care for pregnant women.

"Clinical pharmacy" is also blooming in California. Since 1977 the state has had a law allowing doctor-supervised nurses, physician assistants and pharmacists to prescribe and monitor drugs in a five-year pilot program. The University of Southern California has trained 29 pharmacist-prescribers who now work in hospitals, nursing homes and mental-health centers. Just last week Governor Jerry Brown signed a bill allowing physician-supervised pharmacists, with training, to adjust and monitor the dosage of a patient's drug therapy in institutional settings.

The Medical University of South Carolina, as well as other schools, is training clinical pharmacists and family doctors to work as teams with an eye to setting up joint practices. At the Lexington (S.C.) Family Practice, Pharmacist Bob Davis takes detailed drug histories and reviews medical and laboratory reports on patients, checking for allergies, drug duplications and possible drug interactions; consults with the physicians on appropriate medications and dosages; and follows up on the patients.

Some physicians call the clinical pharmacist "another undertrained superspecialist" and voice concern about fragmentation of medical care and potential liability problems. Others see the pharmacist practitioner as simply superfluous. But many doctors who work with pharmacists seem delighted. Says Dr. Alan Steinbach of the Rockridge Clinic in Oakland, Calif.: "They take the pressure off the doctor and make the patient happy."

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