Professional abstinence: What does it mean for pharmacists?

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Imagine living with a chronic medical condition, such as rheumatoid arthritis, which requires daily medications that have unpleasant and rare, but serious, adverse effects. Perhaps you already do. Now imagine visiting your pharmacy to pick up your regular medications. What if the conversation went something like this:

Patient: I’m here to pick up my methotrexate and hydroxychloroquine.

Assistant: Here they are. You were out of refills for the folic acid, though, so we faxed the doctor. It will probably take a few days.

Patient: But I’m right out of folic acid and if I don’t take it, I feel terrible. My methotrexate dose is tomorrow. Can you ask the pharmacist if she can extend my prescription? You can see I get my lab work done regularly.

Assistant speaks to pharmacist and pharmacist checks the computer. . . .

Assistant: Sorry. The pharmacist isn’t comfortable doing that. . . .

There is an increasing body of evidence suggesting that pharmacists are not engaged in advanced patient care activities such as prescription renewal, patient assessment and independent prescribing.^1-4 We believe that this behaviour is apparent in both novice and experienced pharmacists, and we fear its influence on students, recent graduates and the profession. It is found in all pharmacy practices and we call it “professional abstinence.”

Merriam-Webster defines abstinence as “the practice of choosing not to do something.”⁵ We define professional abstinence as consciously choosing not to provide the full scope of patient care activities. The aim of this article is to consider some root causes of professional abstinence.

As professionals, pharmacists are responsible and accountable for the delivery of care to patients, communities and society.⁶ The professional role is not just a competency but an embodied identity that guides pharmacists regardless of their expertise or practice setting.⁶ As such, pharmacists should inherently apply the principles of best practice, adapt to fulfill evolving roles and seek guidance when uncertain as outlined in the competencies for pharmacy student education and the provincial regulatory codes of ethics and standards of practice.^6-8 Given that available knowledge is increasing every second and that scope of practice is dynamic, what it means to be a pharmacist must continue to change. If pharmacists are committed to their professional identity and the care of their patients, they will remain engaged in the profession and learn what they need to know, do and be, to embrace advanced care activities.^6,9,10 On the other hand, pharmacists exhibiting professional abstinence may defer decision making to another professional due to their unwillingness to accept responsibility and accountability for possible outcomes.¹¹

Researchers have endeavoured to identify barriers that limit practice change in an attempt to facilitate pharmacists’ practice away from the status quo. Pharmacists cite lack of knowledge as a barrier; however, continued learning and refreshing of knowledge is paramount to maintaining the professional role and identity. Lack of available specific patient information is also frequently identified as a barrier, but even in cases where pharmacists have all pertinent and available information, they often show a reluctance to make decisions.^11,12 Finally, pharmacists state a lack of remuneration as a barrier to adopting advanced patient care activities. Research has demonstrated that payment for services does not consistently lead to improved uptake of advanced patient care activities.¹³

At what point do some practitioners lose their enthusiasm for providing optimal care? Lack of time due to workload and lack of confidence have been foremost in pharmacists’ defense of maintaining practice status quo.^1,9 It may also be a culmination of damaging experiences causing a loss of confidence and/or an uninspiring work environment. In a recent publication, employer support to offer advanced services and perceived utilization of clinical skills was linked with professional satisfaction.¹⁴ Barriers shown to impede job satisfaction were regulatory changes and reduced autonomy in practice.¹⁴ Nationally, regulatory barriers are being broken down, though they remain variable across the country. Pharmacists have the ability to ensure continuity of care and prescribe for ambulatory conditions (“minor ailments”) and/or chronic disease management, increasing their autonomy in practice. We acknowledge that major steps have been made in the right direction through legislation and payment models; however, we know that there is still work to be done.

While some pharmacists are influenced by positive role models and mentors in practice, others have negative experiences. There may be a disconnect between the idealized model of pharmacy and actual practice, where pharmacists see a mismatch between what they have been taught and what they see and experience in practice. This may lead to confusion over their identity as professionals.^9,15 An apathetic colleague or manager can also have a negative effect on whether a pharmacist considers evolving roles as his or her career progresses.

To move forward, pharmacists need to be confident in making decisions; however, the literature reveals that they are often hesitant to make any clinical decisions.^11,12 When pharmacists defer clinical decision making due to a perceived lack of information, they often refer the patient to a physician. Not making a clinical decision in this case is still a decision, a decision to avoid responsibility for care and potentially put the patient at risk.¹¹ This behaviour has been called “buck-passing.” We are not encouraging pharmacists to practise outside of their knowledge, skills and abilities, as this poses a risk to the patient. We assert that situations where pharmacists have access to information and the competence to make a decision but do not engage in providing the necessary care are cases of professional abstinence.

Recent work has shown that there are 9 facilitators for practice change (“the 9 Ps”), 3 of which are pertinent to professional abstinence: peer referencing, practice and professional identity.¹⁶ Pharmacists who reference their practice with a peer can shape and redirect behaviours promoting practice change. The opportunity to practise new skills in a safe environment and the selection of a simple initial case to apply the skills can help build confidence and reinforce positive behaviour. Having the opportunity to construct responsible and accountable aspects of professional identity early in practice through experience and mentoring can also help foster and model development of an advanced patient care practice.

What can individual pharmacists do? Find peers and shadow them. Find mentors who have grown their knowledge, skills and abilities through varying experiences. Precept students and reciprocally learn from them. Reconstruct the narrative that we do not know enough or have enough information. Make and influence simple care decisions that positively affect patients and be accountable for the outcomes. Amass competence and confidence through repetition. There are many system and policy impediments, but by slowly changing what we do, how we think and how we engage in patient care, pharmacists will continue to evolve along with practice.

If we do not disrupt what we have defined as professional abstinence, pharmacists will be deprived of the opportunities provided through education, experience and legislation. Our professional identity will be at risk of being dismantled. Instead, focus on growth and adapting together so all Canadians can experience exceptional care from every pharmacist they encounter.

Alternate vignette

Patient: I’m here to pick up my methotrexate and hydroxychloroquine.

Assistant: Here they are, but can you just wait a couple of minutes? The pharmacist wanted to talk to you quickly.

Patient: Okay.

Pharmacist: Hi. I just wanted to let you know you were out of folic acid refills, but I extended the prescription so it matched up with your refills for methotrexate. I checked your blood work and it all looks good. The next time you are in to see your rheumatologist, you’ll need to get some more refills for that.

Patient: Oh, that is great. I feel just terrible if I don’t take the folic acid, so this is perfect. I’ll be seeing my rheumatologist in 3 months, so will get refills of everything then. Thank you!