Prescribing powers for pharmacists

At a time when the impact of diagnostic error on patient safety is finally being appreciated, the news that pharmacists in Alberta will be allowed to diagnose medical conditions1 will generate alarm and some despondency among researchers in this area.

There is now abundant evidence that delayed or missed diagnoses are widespread and that in more than 50% of such cases there are serious adverse outcomes. They are the primary source of litigation against both family physicians and emergency physicians.2 Not infrequently, apparently simple presentations of illness turn out to be incipient catastrophes. Dissecting aortas present as constipation; subarachnoid hemorrhages as muscle tension headaches; acute myocardial infarctions as stomach upset; and meningitis, encephalitis, cavernous sinus thrombosis, peritonsillar abscess and epiglottitis as the common cold. It is extremely easy to be fooled, and one is more easily fooled when one fails to elicit a history of the presenting illness and a relevant past medical history and to perform a physical examination. The money that pharmacists will have to pay for $2 million in personal professional malpractice insurance1 will be well spent.

Besides this overarching safety concern, the other major problem is the potential for conflict of interest: pharmacists have a commercial interest in what they prescribe. Pharmaceutical companies will certainly waste no time in “detailing” pharmacists. Sadly, physicians have adapted poorly to the variety of creative, insidious and sometimes unethical marketing practices that the pharmaceutical industry has used to influence them.3 Human nature being what it is, pharmacists will be especially vulnerable in this regard owing to their proximity to the patient–medication interface.