Professional abstinence: What does it mean for pharmacy students (and our future. . .)?

“Consciously choosing not to provide the full scope of patient care activities”—this is the definition of professional abstinence, a term coined by Biggs et al. in CPJ in 2019.¹ In one of the journal’s most downloaded articles of the past year, the authors stated their grave concern about the impact of professional abstinence on pharmacy practice and its influence on our students, recent graduates and ultimately, the profession.

It is a serious threat if the future of our profession—that is, students—is besieged by poor professional role models (“abstainers”). No amount of regulatory progress toward a full scope of practice will make any difference if pharmacists choose not to apply that scope in their provision of patient care. This threat was analyzed by Noble et al.,² who surveyed pharmacy students on professional identity formation at a pharmacy school in Australia. Their analysis of student anecdotes illustrated that when there is discordance between the idealized role of the pharmacist (as taught in their curriculum) and the perceived role of pharmacist preceptors in practice, the resultant tension led students to view the profession as both constrained and limited. It is clear that the pharmacy profession must continue evolving toward responsible patient-centred care. Although students are taught the concepts necessary to do so in class, an issue arises when a pharmacist preceptor demonstrates the opposite in practice; these demonstrations imply a message of “that is not what we do in the real world.” This sets students up for disengagement with the scope of pharmacy practice, representing a major threat to the future of our profession and the patients we serve.

To illustrate this point, here are some examples pharmacy students at the University of Alberta shared with us:

• Case 1:

•  What happened?

•   • “The patient came in with complaints of not being controlled on their blood pressure medications, but the pharmacist chose to opt out of adapting the dose of an angiotensin-converting enzyme inhibitor (ACEi); they faxed the doctor instead!”

•  How did it make you feel?

•   • “I asked the pharmacist why they didn’t adapt, and they just said that most patients never know why they are even taking an ACEi, since it has so many indications, so the pharmacist wouldn’t know how to titrate the dose. I thought that might be fair, but the pharmacist didn’t even bother asking the patient—they just assumed, so I felt kind of disappointed and helpless.”

• Case 2:

•  What happened?

•   • “A patient called in asking if the pharmacist could prescribe antibiotics for pain—the pharmacist just did it without asking any questions. They told the student who answered the phone call to just say yes.”

•  How did this make you feel?

•   • “I felt as though the pharmacist should have assessed the patient more and asked more questions. This also adds to antibiotic resistance. It didn’t feel fair to the patient, because their life is basically in the pharmacist’s hands.”

• Case 3:

•  What happened?

•   • “The pharmacist would do the bare minimum during their shift. It reached a point where the district manager had to bring in a pharmacist from out-of-store once a week to do CACPs and SMMAs. There was just no incentive for the store pharmacist to do them even though these had been designed to give the pharmacy, not the pharmacist, compensation. There is no incentive for a pharmacist to do more or to be better on top of their already excessive workload.”

•  How did it make you feel?

•   • “It wasn’t actually all that discouraging. If anything, it makes me want to take part in creating policy. I don’t think it’s the pharmacist’s fault either. I think it may be up to the pharmacy owners to create their own incentives. I asked the pharmacists why they didn’t do any of the Comprehensive Annual Care Plans (CACPs) or Standard Medication Management Assessments (SMMAs), and they told me it was because they don’t get paid more.”

• Case 4:

•  What happened?

•   • “Not checking indication when checking prescription: patient was receiving trimethoprim/sulfamethoxazole (TMP/SMX) for the first time, and the pharmacist dispensed the medication and counselled on side effects but never asked the patient what they were taking it for. When I asked why, the pharmacist said that even if the indication was incorrect, it would be difficult for him to oppose the doctor, so he prefers not to ask much anymore. On another occasion, a different patient came in asking if there were anything they could take for a skin infection or injury, but the pharmacist immediately referred the patient to a physician without asking too many questions or even performing SCHOLAR.”

•  How did this make you feel?

•   • “Very discouraged—this prevents pharmacies from becoming more than just dispensaries; we take all this clinical education for a reason.”

From just these few anecdotes, it is clear that when pharmacists choose to practise below their scope, students recognize this choice and react negatively to it. Discouragement, helplessness and disappointment—these are all emotions that signify the gulf between what students witness in practice and what they are being taught in the classroom. However, despite recognizing the gap, no student reported acting upon it. Instead, the behaviour of pharmacists may be creating a disengagement in students, where they accept this suboptimal practice. As the dissonance forms without a means to reconcile it, students’ future engagement in practice is influenced.² So professional abstinence can become the reality of practice in the eyes of students, which is nothing short of unacceptable.

The impact of professional abstinence on students’ professional identity is dangerous for the patients we care for and the future of our profession, as a whole. Professional identity formation is a “foundational experience resulting in the transformation of an individual from being ‘just’ a person to being a [physician].”³ This could be further extrapolated to state that professional identity formation is a necessary experience that changes a person from being “just” a student to a health care professional—in our case, a pharmacist. These experiences are iterative and involve forming core values, self-awareness and self-regulation principles,³ which are influenced by context, such as individual factors, preceptor-to-student interactions and societal expectations.² Choices made in practice are then informed by the values and ethics formed in alliance with one’s professional identity.² Health care practice entails working in ambiguous situations in which correct answers or choices are not black and white; to continue operating in the grey, this developed sense of professional identity is necessary support for clinicians. In other words, professional identity is an important part of what motivates practice³; it drives professionals to provide optimal patient care, regardless of any observed line between reality and the ideal. At best, weakened formation of a professional identity leads students to view their role in a constrained way instead of believing they can be and are agents of change.² In the worst-case scenario, students go on to adopt what they have witnessed, and the pharmacy profession will continue struggling to become fully patient centred.

So what can we do? Clearly, as a profession, we need to change our culture to one in which professional abstinence is unacceptable. As a first step, to further elucidate the current state, we propose a registry of abstinence issues. In this anonymous registry, we will ask for examples, or “stories” of professional abstinence from pharmacy students across Canada, who are in a unique position to see them. Narratives and story-telling have been demonstrated as a means of building resilience in medicine,⁴ a quality necessary to change culture. The themes developed through the narratives will be shared and used to explore the role of pharmacy students in addressing professional abstinence. When students have the resilience to reconcile the constraints they witness in practice, we will be one step closer to changing pharmacy culture.

To participate, please visit https://www.epicore.ualberta.ca/home/enact/. Let’s be proactive—for our patients and for the future of our profession.