How we are progressing towards the goals of the manifesto

With the establishment of the College of Psychiatric and Neurologic Pharmacists (CPNP) manifesto and Dr. Stimmel's vision, our members need to evaluate how we as a profession are progressing toward or away from the goals and mission statement of the manifesto. The manifesto correctly states that the public and most health care providers view pharmacists in a dispensing role. However, polling the CPNP Past Presidents' Council, the majority believe the manifesto will become obsolete and in need of revision in ten years. The ability to make the manifesto “obsolete” and “commonplace” rests on how our profession navigates the legislature that governs our laws and ability to provide favorable patient outcomes and expand our role within the health care team.

CPNP has made strides over the past several years in addressing legislative concerns regarding our profession and our capacity to provide and expand our abilities to take care of patients. CPNP established a Legislative Committee to address the regulatory issues that may affect us. Over the past two years, CPNP's Legislative Committee has worked diligently in drafting letters to Congress and keeping us informed of potential legislative changes that may affect our profession. For example, the American Medical Association (AMA) recently proposed to limit the role of pharmacists. The reaction was a cogent response from multiple organizations (CPNP included) to the AMA's errant claims regarding a Pharmacist's training and our ability to provide direct patient care. Additionally, physicians who have a favorable working relationship with pharmacists also provided details of their successful collaborative practices. As a result, the AMA original proposal was amended. Consequently, we need to not only continue to develop and foster working relationships with physicians, but educate the public on the positive outcomes resulting from pharmacy services.

With the advent of robotics (e.g., RIVA, UCSF Robotic Pharmacy), our traditional dispensing roles will soon become a relic. It is also just a matter of time before robotics will be able to provide basic counseling as well. Therefore, if we are to survive, we need to look at other avenues which may provide logical strategies for our ability to provide and bill for services. The published literature states we have been successfully working with psychiatrists for almost 35 years in both inpatient and outpatient settings.^1–4 More recently, several states and institutions have been at the forefront in developing auspicious collaborative practices with physicians.^3–6 For example, the Medical Board in North Carolina has granted prescriptive authority to pharmacists with advanced training; however, they continue to have difficulties billing for services. Although there has been an increase in published data, psychiatric clinical pharmacists in these settings should continue to work diligently in disseminating their outcomes.

Educating the public and politicians regarding our training and ability to do more than “dispensing” can be tedious and frustrating at times. The battle for privileges among our profession is perhaps the most daunting. If we are to fulfill the manifesto's vision for the future, we need to step out of our comfort zone and challenge traditional thinking. At this time, two central issues among our profession exist: billing for services and ability to prescribe. Both issues have created a schism which we need to resolve if our profession is to progress.

The key is to have the majority of pharmacists and pharmacy organizations agree on what we feel should be our primary target. Our discussion boards have echoed that perhaps pursuing prescription authority on a more global scale should be the first step in our ability to bill for our services more effectively. Others have argued that they “do not want the responsibility” of prescribing. However, this may be considered obtuse thinking since if one does not want “the authority to prescribe”, then they do not have to partake in it. Prescriptive authority can be limited to those who have board certification, completed a year of residency, undergone a specialty training similar to North Carolina's, and/or be limited in scope of practice. Guidelines regarding prescriptions would need to be collectively established by the Boards of Medicine and Pharmacy. Similar to medicine where different practices pay different insurance premiums, pharmacy insurance would need to develop different tiers to rest concerns regarding the potential increase of insurance for those who do not want to prescribe.

Physicians, including psychiatrists are at the brink of exhaustion.⁷ Hospital administrators continue to ask psychiatrists to see more patients within a limited time, and discharge patients at a faster rate. How often have we been in an inpatient psychiatric setting and seen someone discharged earlier than needed to the chagrin of the psychiatrist because of external pressures (e.g., insurance does not cover after 10 days) and influences from administrators? This has been recently elucidated in a study which rated aggressive administrative environment, lack of support from management, and long work hours as causative factors for psychiatrist burnout.^7–9 The world of psychiatry and neurology offers clinical pharmacists the opportunity to become a valuable asset to the multi-disciplinary team and decrease the frustration of the psychiatrist. Often, no one knows more about the adverse events, drug interactions, kinetics, and pharmacology of the cornucopia of psychiatric medications that are prescribed. Our role to assist psychiatrists or neurologists in streamlining medications, managing adverse effects (e.g., tremors, metabolic complications), and drug concentrations will ease their burden and ultimately provide safer, faster, and more favorable patient outcomes. However, the inclusion of a psychiatric or neurologic clinical pharmacist as a part of the multi-disciplinary team is still absent in many parts of the United States.

Data demonstrate nursing students and physicians do not get enough training regarding pharmacology and calculations. In a 2004 study, only 10% of medical residents could correctly calculate three dosing questions, while 27% answered all three questions incorrectly.¹⁰ Another study showed nursing students have a perception of lack of pharmacology knowledge and feel medication management is an area of concern.¹¹ As a result, we currently communicate with prescribers regarding medication related issues (e.g., dosing, drug interactions) and counsel patients regarding their medications (e.g., how long to take, side effects). Despite our services within the multi-disciplinary team, our inability to routinely bill for such services greatly affects us. Currently, pharmacy directors in this economy struggle to justify hiring additional clinical pharmacists. At times, pharmacists spend valuable time tracking interventions with an “associated cost” so that we may justify our place in a clinical setting to the administrators at the hospitals. Regardless, residency positions in some parts of the country continue to close within institutions or additional clinical pharmacy positions or residencies are rejected because pharmacy could not provide more objective evidence of direct cost savings associated with our services.

It may be argued that with prescription authority, we may have an easier time justifying and billing for our services including the ability to provide patient counseling. Once these issues become commonplace, it may be easier for an institution (e.g., hospital) to hire additional clinical pharmacists since we will be able to provide a more objective base of cost vs. benefit. As we move forward over the next ten years, CPNP must continue to work with other organizations (e.g., AAFP, NAMI, ASHP) and health care providers to promote our profession. Traditionally, history has taught us that generally, one cannot win when fighting two fronts. Therefore, a decision must be made on which issue we should primarily focus on first: billing for services vs. prescriptive authority. Only then, will we be able to ultimately entrench ourselves into providing direct patient care within the multi-disciplinary team.