s An Evidence-Based Conversation Between Ken Harvey, Gerald Quigley and Neil Johnston- Part 2 | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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Recent Comments

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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An Evidence-Based Conversation Between Ken Harvey, Gerald Quigley and Neil Johnston- Part 2

Neil Johnston

articles by this author...

Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.

Following the first conversation between Dr Ken Harvey, Gerald Quigley and Neil Johnston, which was recorded in last week’s update to i2P, Dr Ken Harvey stirred the pot a little by sending a letter to the editor with sufficient content to stimulate a second conversation.
What follows below is a copy of that letter with comments by the original participants.
Readers who have not read the first conversation should visit this link.

Ken has also placed additional comment on site at the foot of this original “conversation”
Anybody reading this material is invited to comment through the panels at the foot of the article (s). Gerald and I would particularly like to hear from pharmacists who may be feeling constricted within their own practice by being herded into a channel of activity that is uninspiring through lack of challenge and incomprehensible when you try to deal with “evidence” that is contradictory or developed from a fraudulent base.
What follows is Part Two of our tripartite “Evidence Based Conversation”.

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Dr Ken Harvey:

“You need to add to our original conversation that subsequently a pharmacist from Pharmore Pharmacies did respond to my concerns and I took up her offer to make contact by telephone. She mentioned that Pharmore sales assistants had been trained by BioCeuticals which Pharmore believed was a reputable company and she felt the NPS advice was merely one opinion amongst others that she referenced.
(Editor’s Note: This was included in the first conversation) 

Andrew Daniels, Managing Editor of the “Australian Pharmacist” kindly provided me with the Lisa Oates’ article she cited. Lisa said, “Whether co-supplementation of CoQ10 with statins actually counteracts the adverse reactions requires further research”. She went on to say, “Given the apparent low risk of CoQ10 supplementation and potential benefits it may be worth supplementing CoQ10 in patients taking statins, especially those at increased risk of deficiency or with a family history of heart failure.”

Lisa did not point out the risks of this “companion sale” approach; with increasing co-payments and safety-net thresholds a number of patients are already forgoing necessary PBS drugs because of their cost  to the potential detriment of their health. Adding extra “companion” complementary medicines increases the cost and medication burden to patients for potential benefits that have yet to be proven.  

Lesley Braun has written more recently an article titled, “What role for CoQ10 with statin drugs?” in “The Australian Journal of Pharmacy” Vol 93, January 2012. In a nice review of the literature she noted that it has been postulated that CoQ10 depletion may be part of the aetiology behind statin-associated myalgia but she made no recommendations herself about routine companion sales for prevention.  With respect to statin-associated myopathy she observed (as did the NPS) that there were only two small studies investigating whether CoQ10 administration could myalgia and these had conflicting results. Given the safety profile of CoQ10, like the NPS, Lesley noted that a trial of CoQ10 may be warranted in a symptomatic patient.

This incident has received some publicity and comment in “Australian Doctor”. For example, “A patient I had prescribed a statin to came back for review and said that the "pharmacist" had told her that this medication caused tiredness and she should buy a bottle of "this " to prevent tiredness. This product was a bottle of coenzyme Q10 , which no doubt cost her much more that the actual prescription. I phoned the pharmacy and spoke to the pharmacist to ask why she had been asked to by this product given that she had not been prescribed it and that it was not asked for by her, not needed and of no benefit at all. He said he did not know and it was most likely due to a pharmacist assistant being too enthusiastic.!! Pharmacists unfortunately discredit themselves as scientists and professional people by peddling these useless products for their own gain”. See: http://www.australiandoctor.com.au/news/latest-news/pharmacists-push-antioxidants-with-statin

I had problems with your comment,  “What was needed (and still is) was a pharmacist qualified in clinical nutrition responding to a patient request and taking a full history of all circumstances. Preferably, this pharmacist should have a degree of “arms-length” from the pharmacy owner, but that is not an absolute necessity. After a full investigation of the patient’s circumstances and a need is found for nutritional supplements, then a recommendation can be ethically made”.

I’m a great believer in the value of doctor-pharmacist teamwork. By asking how a patient is getting on when dispensing repeat ‘scripts a pharmacist may well discover a problem that the prescribing doctor is unaware of. Surely, the right approach is to suggest that the patient goes back to the doctor to be reassessed. It is quite reasonable to mention to the patient that if the doctor felt, for example, that myalgia was likely to be caused by the statin then there a number of options were available that may relieve the patient’s symptoms, such as lowering the dose, changing to another type of statin or recommending CoQ10. But in my view this decision (about the management of prescription drug side-effects) should be the doctors; not the pharmacist.

Gerald asked, “So do we pharmacists take responsibility or not? Do we have the balls? Of course pharmacists should take (and do have) the responsibility to ask patients about their symptoms and possible side-effects of medication. Of course they should (and I believe do) have the training to give good advice on OTC products for the management of minor conditions. But they also need to know when to refer back to the treating doctor. It can assist the pharmacist-doctor relationship if this referral  is accompanied by helpful suggestions, for example, “do you think CoQ10 might assist this patient with statin-associated myalgia?”   

But, in my opinion, abdicating this role to a pharmacy assistant trained by a complementary medicine company  is not the way forward.

 Gerald also said, “Or is it evidence that has to pass some other authority for a tick of approval before we act?” I have pointed out that there are professional bodies such as the NPS that have considered the totality of the evidence and made considered recommendations. I happen to agree with their conclusions. The  issue for pharmacy is should they take notice of such bodies or do they consider the NPS just another “opinion”, to which their own (on reading the odd reference) has equal weight?
And three final points:
* I agree that not all my medical colleagues are as open to listening to pharmacists as they should be. One way I try to break down these barriers is to insist that local pharmacists are  invited to my Victorian Medical Postgraduate Foundation (VMPF) country GP continuing education sessions.  Discussing cases together can show that each profession has their own complementary expertise.  

* I also accept  that the behaviour of some doctors, scientists and drug companies  leaves much to be desired with respect to unethical behaviour. In this regard, I do what I can by submitting complaints and trying to improve Codes of Conduct. However, I do not accept Neil’s proposition that no pharmacist should be criticised until such time as we have cleaned up everyone else.

* Finally, Gerald loves to provoke me with statements such that, “cognitive decline, recognized as an inevitable adverse effect of statin therapy, is being ignored”. As I pointed out in a comment on our first “conversation” (14/05/2012) the literature does not support Gerald’s fears.  

Neil Johnston:

Dear Ken,

The references to the "coke and fries" approach I think were adequately dealt
with by Gerald and me. In summary, we do not support unqualified up-selling where a pharmacy assistant approaches the patient (nor do most pharmacists).
We do support the provision of information by a pharmacist where the patient approaches the pharmacist with such a request. And that may result in a recommendation to take a product that may (or may not) be copied in for GP records. It is the patient's choice.
Two totally different responses!
There are degrees of collaboration between GP's and pharmacists - not all of it performed in a satisfactory manner by either side.
The incomplete comment you quoted as part of the Australian Doctor presentation concluded with "And no , I do not think doctors should be obliged to learn about alternative medicines. We are doctors not witch doctors." – and that left me totally unimpressed.
I would not be prepared to collaborate with a GP who has this type of mindset because that is promoting ignorance.
I am a qualified clinical nutritionist and I am well aware of the benefits it can provide.
Unfortunately, most GP's seem to have this attitude and are very disrespectful toward any attempt by a pharmacist to share information (I have the scars to prove it).
So when Gerald says "do we have the balls" he is really saying are pharmacists prepared to engage with the medical profession in mortal combat and knock them off their ivory tower.
The alternative is simply to go it alone under the radar, as many are forced to do.
The combative attitude by the medical profession towards pharmacy and other health professions has been too one-sided for too long. As I have consistently pointed out, they pronounce all evidence as faulty unless it comes from within their custody.
Yet nothing is being done in Australia about the blatant academic fraud (particularly in cancer research) and tidy up their own backyard first.
Which Australian Journal/publication (except for i2P) even talks about it?
Patients are turning to alternate practitioners in large numbers because they are tired of the impersonal doctor service they receive with "evidence-based"prescription drugs that do not seem to work.
Globally, there now seems to be a momentum to speak out against what is described as a ‘dysfunctional scientific climate’ that has created a ‘winner-take-all game with perverse incentives that lead scientists to cut corners and, in some cases, commit acts of misconduct.’
But elsewhere, audacious, falsified research stands unretracted–including the work of authors who actually went to prison for fraud!
Before anyone starts to waste energy to keep pharmacists in line over coenzyme Q10, start retracting published papers and clean up the science first.
Then, and only then, will medical science be respected, (but not necessarily taken on board by a pharmacist health practitioner unless it gels with their own evidence base and experience).


Gerald Quigley:

I find it interesting that cognitive decline, recognized as an inevitable adverse effect of statin therapy, is being ignored here. The emphasis on myalgia and rhabdomyolysis is a handy distraction on some of the issues at hand.

Let’s again shift the focus away from what the academics say to what our patients tell us, sometimes if we ask them questions, or aren’t we allowed even to do that without dispatching them back to their (uninformed through no fault of their own) medical advisor?

This constant overwhelming emphasis on so-called ”evidence” is a very reassuring in that we don’t, if we wish, have to get involved at all. Just dispense, take the money and be happy. Is that what we are? I’m actually more concerned at the latest “evidence” that statin therapy is not proven to reduce cardiovascular risk unless there’s been a previous heart attack. But hold on, that’s just evidence we choose to ignore.

What about the patient? What about our care? What about the expectations we offer the patient. Note that I’ve said “patient” not “customer”. Customers buy, but patients want a solution to their health challenges. The academics have confused the two completely.


In summary:
1. Ken seems to be doing some good work to promote collaboration between GP’s and pharmacy. This is definitely a positive and I hope it catches on to allow respect to build.

2. The old adage that “people in glass houses should not throw stones” was the message that I was trying to get across (not that pharmacists should be immune from criticism). How can anyone feel that their evidence base is pure and pristine when the opposite is being proven on a daily basis?

I was moved to compile a separate record of some falsified evidence for this update just to illustrate the extent (See Friends of Science Fiction in Medicine).
How can the evidence around “statins” be trusted in the first place?

3. Gerald’s focus on patients and their care is extremely valid. He highlights the cultural differences between pharmacists and doctors and hints at the type of care acceptable to his patients.

A pharmacy patient arrives generally as a refugee from the medical system or is one seeking acceptable care, having not received adequate care elsewhere.
Or, quite commonly, they arrive after a conversation in the pharmacy and like what they hear.
Often, a pharmacy patient is a shared patient with a GP.
It is this latter perspective that is not agreed to by a GP as they keep positioning pharmacists as only having “customers”-they reserve the “patients” for themselves.
Stop Press - I have just received a late email from Gerald.
I do feel concerned that Ken feels I’m provoking him!
My issue is that that the “evidence” argument clouds what we find clinically. And in the case of CoQ10, the loss of cognitive function is, in my opinion, much more sinister that myalgia which is much more evident, and can be a yes/no answer by a patient.
As I have said many, many times, what’s happened in our profession that we can’t think for ourselves any more, we can’t have an opinion, we hide behind academia, and we no longer accept responsibility for actions which we can, and should, initiate at patient level?
Do the institutions have some responsibility here, by not accepting that we face real people every day in whatever aspect of our profession we follow?
Cheers, Gerald”

Obviously, much work is needed to create more positive attitudes between the professions. The doctor as “god” is no longer acceptable.

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