Mandatory consulting lacks a consensus

Drug Store News, Jan 22, 1990 by Elizabeth Richardson

Mandatory consulting lacks a consensus

A woman goes into her neighborhood pharmacy to fill a prescription for Paregoric that simply says "Take as directed." The pharmacist routinely asks her: "Did your doctor tell you how to take this? Did you understand what the doctor told you?" She replies, "Yes, I know how to take this medication." Pressing on, the pharmacist asks the patient exactly what the doctor told her. She replies, "He said to hold her nose 'cause it tastes bad, and to give her two ounces." Upon further investigation, the pharmacist discovers the prescription is for a six-month old baby. Knowing the instructions were incorrect, he immediately calls the doctor. The woman is threatening to take the prescription elsewhere, because the pharmacist disagrees with her. Subsequently the doctor changes the directions and tells the woman that the pharmacist saved the life of her young child.

The story is a true one. It was related to us by David Clark R.Ph., executive director of the Indiana Pharmacists Association, who is also the pharmacist in the story. He tells the story to make a point about meeting the requirements of mandatory consultation legislation. At what point in the above scenario was patient consultation fulfilled? When the patient answered, "Yes, I know how to take this medication?" or when the pharmacist delved further for more information?

This question is just one of many surrounding the controversial subject of patient consultation, which many states would mandate. While proponents and opponents alike agree that patient consultation is crucial to the future of pharmacy, both sides do fierce battle over the question of mandating the practice. With no real consensus in sight, this issue is sure to be a heated debate well into the '90s.

The discussion of patient counseling is nothing new to pharmacy. Pharmacists for years have reiterated that they consult on a regular basis. Court cases revolving around the issue date as far back as 1934 (Fuhs vs. Barber), when a patient was awarded $1,000 because her pharmacist was found guilty of negligence, failing to tell her about an interaction of two different treatments for poison ivy.

Today's issue involves the question of whether a regulation is a hindrance to the pharmacist - will new laws just make the pharmacist produce minimal effort just to satisfy the law? State industry executives differ in their answers.

"The purpose of a regulation is to publish a community standard, which enables the consumer, the professional and the regulator to more clearly distinguish behavior which falls within and outside the professional standard of practice," said Lorie Rice, executive officer for the California State Board of Pharmacy.

California is one state currently working to implement regulations for mandatory consultation. "Without that mandate, a consumer would call our state board of pharmacy and the board could really only say, `Find a new pharmacist,'" Rice explained. "With mandation [sic] we would have a separate recourse to help remedy the situation."

Other industry leaders feel that pharmacists will react by involving themselves in minimal consultation just to fulfill their legal obligation.

"Patient counseling, in my opinion, is too important to be merely another of a long list of mandated motions," said Dr. David Clark, executive director of the Indiana Pharmacists Association. "Will pharmacists come to view mandated patient counseling like they view more third-party paperwork?"

So far, approximately 18 states either require consultation or greatly encourage it. About five other states are actively pursuing a regulatory stance, according to Carmen Catizone, executive director of the National Association of Boards of Pharmacy (NABP). His association, which endorsed mandatory consultation last year, is conducting committee work this month on the issue. Catizone feels that a model set of regulations may be the end product of the committee.

"We think it's time that the state boards took an active role," he said. "It has now become a legal question. We're moving in the direction toward mandatory requirements."

States currently addressing the issue have similar regulatory outlines. Pharmacists will be required to consult on all new prescriptions; a refill with a change of strength, dosage form or directions; a prescription the pharmacist feels requires consultation; on patient medication profiles; for ambulatory patient care settings; and when the patient asks to talk with the pharmacist.

California's Board of Pharmacy could be the first regulatory body to mandate consultation. The proposed regulation was sent to the California Office of Administrative Law (OAL) in November, but was disapproved in December due to clarity issues, involving the definition circumstances of "patient profiles." However, the issue of "mandatory counseling" was not disapproved, according to Patty Harris, assistant executive officer of the California state board.

"We have cleaned up the language and will resubmit it to the OAL," she said. "We should receive a decision by the end of January, but we anticipate no problems."