s Roadblocks in Clinical Services Provision | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists


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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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

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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

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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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Roadblocks in Clinical Services Provision

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.

I have been reading with interest, Peter Sayers' journey into paid professional services and his cautious optimism.
Now, as a feature article in this current edition of i2P John Dunlop, a respected New Zealand pharmacist, expresses doubt that clinical pharmacists are going to make it in a community pharmacy setting.
Further, Professor Austin Zubin at a recent PAC2013 conference in Brisbane identified a problem amongst pharmacists he describes as ‘Paralysis in the face of ambiguity’ as he pondered why pharmacists were not taking up opportunities in primary health care.
“Despite abundant opportunity and patient demand, government recognition etc, across the world, a similar picture emerges of a profession that is its own worst enemy,” he said.
 “The standard response to new opportunities is, ‘I don’t have enough time, I’m not trained for this, I’m not getting paid enough, it’s too costly….”

He has been involved in researching this perceived problem through the Faculty of Pharmacy at the University of Toronto in Canada and an abstract is published further along this article to which I will add comment.

But before I progress to that point I would like to comment on some aspects of my early pharmacy training that commenced at around the last intake of apprentices under what has become known as “the old phart system”.
In that system, the apprentice was at the bottom of the food chain washing bottles, cleaning shelves and putting away orders. That gradually progressed to making up bulk solutions to facilitate quicker compounding or bulk preparations of a standard formula.
It was seen as drudgery, but it was the pathway to “earning your stripes”.
Above me was an unregistered pharmacist, a dispensary manager (registered) and an 82 year old master pharmacist (an ex-Newington rugby half-back).

I didn’t fully appreciate it at that time, but these were my mentors-not only for pharmacy skills but for life skills as well.

As I progressed I was mentored in the skills of counter prescribing and the diagnostics required to support that practice. There was no later university course covering these subjects and I was advised that you never used the words “prescribe” and “diagnose” in a setting where you could be attacked by members of the medical profession.
Nonetheless, this is what actually happened and I developed skills to the extent that patients asked for me by name when they wanted information on their pharmacy visits.
I always marvelled at the strength of the patient list my master pharmacist had and when an unaligned patient came into the pharmacy, it was like a rugby ruck as all the pharmacists literally ran to offer their services.
Despite his 82 years age barrier, my master pharmacist inflicted many a bruise as he rudely cast me aside with a well-practiced hip roll as he manoeuvred his way to the front of the pack!
And in this I am not exaggerating.

That was my training ground, and as rough as it was, it equipped me to be independent in the “school of hard knocks”.
John, the dispensary manager, was a returned soldier from the New Guinea campaign and he would often enthral me with his tales of how the fight was taken to the Japanese in collaboration with the Americans.
He was very critical of American soldiers who, as he told it, carried all the “garbage” in the world when going out on patrol, gradually discarding it piece by piece as their backpacks weighed them down.
This made it very easy for the Japanese to find allied patrols – all they had to do was follow the garbage!
And for that reason, Australian soldiers would refuse to go out on joint patrols.
The other observation he passed on to me was that because of their independent spirit, if an Australian officer was shot, another would automatically spring up and take charge whether or not they had undergone leadership training.
This seemed to be a natural aspect of Australian military culture which was also missing within their American counterparts-if their officers were shot, confusion reigned because there was nobody else to give orders and casualties became high because of that aspect.
Individualism and self-reliance was something that Australians used to pride themselves on because that was the way Australia had to develop post the First Fleet.
Those stories and many others shaped my pharmacy life and I have never forgotten them.

Moving on, I became a pharmacy manager in different locations and eventually a managing partner in a pharmacy group. This was in the 1960’s around the time pharmacy marketing groups began to evolve.
The fact that marketing groups always seemed to fail irked me and I set out to find the reasons why and as I found answers, those answers helped to transform me into a management consultant.

Making the decision to create a career out of consultancy was one that initially caused a “butterflies” feeling in the pit of my stomach.
I was married by this time, had two very young children with a third on the way and no clients. Also I was endeavouring to provide a service little understood by my fellow pharmacists.
However, an interested Parke Davis sales representative offered to introduce me to a potential client, so I accepted.
And that contact proved successful and resulted in two more introductions to close friends.
When I asked my client why he referred me on when he could have quite easily given them all the information I provided him with, he responded “I paid for my information and they are going to bloody well pay for their own”.
I asked the question because it is quite common pharmacist behaviour to pass information on to friends quite freely.

That gave me my first insight into client behaviour and apart from not having a template to base a consultancy practice on (I was the first pharmacy management consultant) there were significant hurdles to overcome.

Now the point of all the above rambling is to say that while the process was stressful on occasions, never did I vary from my planned pathway. I had the self-confidence to do it (underwritten by a great apprenticeship) and I just got on with it.

I did have input to the PGA/PSA consultancy model, through a researcher retained by them to recommend a format for a consultant pharmacist activity.
I have had to stand back in dismay as to what has been passed off as consultant pharmacy (no independence, no real recognition, not even a client initially-with a discounted payment made by a non-client pharmacy. What a mess!)

As all pharmacists would realise, in all the time since the formation of a consultant association, it has never been representative of consultants (they had no vote and no elected representatives). The range of services has been limited to a medication review service – but no expansion into primary health care activities.
Now the Association of Consultant Pharmacists is in decline with a new SHPA version taking its place.

Over time I developed an integrated clinical nutrition practice operating from home.
Community pharmacy never seemed to be able to accommodate me with a space that was quiet and private.

I have given my story for three reasons.

(i) Pharmacy culture has been dumbed-down and has dampened the spirit of pharmacists.

(ii) Few pharmacists have had independent consultancy practice experience to understand what needs to be in place to deliver a professional service.

(iii) Until recently, PGA leadership has deliberately blocked consultant pharmacist aspirations in favour of a supply chain future for community pharmacy.
Even though they were a 50% shareholder in the Consultant Pharmacist Association it was never meant to flourish because of the threat it supposedly represented to a community pharmacy as an independent business.
Now there is a realisation that an alliance association for both models (community pharmacy + consultant pharmacy) would represent the way forward.

What now follows is the abstract from Professor Zubin’s research published in the Canadian Pharmacy Journal. Read his findings with interest.


Can Pharm J (Ott). 2013 May;146(3):155-61. doi: 10.1177/1715163513487309.

Responsibility and confidence: Identifying barriers to advanced pharmacy practice.
Frankel GE, Austin Z.

Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario.


Despite the changing role of the pharmacist in patient-centred practice, pharmacists anecdotally reported little confidence in their clinical decision-making skills and do not feel responsible for their patients. Observational findings have suggested these trends within the profession, but there is a paucity of evidence to explain why. We conducted an exploratory study with an objective to identify reasons for the lack of responsibility and/or confidence in various pharmacy practice settings.


Pharmacist interviews were conducted via written response, face-to-face or telephone. Seven questions were asked on the topic of responsibility and confidence as it applies to pharmacy practice and how pharmacists think these themes differ in medicine. Interview transcripts were analyzed and divided by common theme. Quotations to support these themes are presented.


Twenty-nine pharmacists were asked to participate, and 18 responded (62% response rate). From these interviews, 6 themes were identified as barriers to confidence and responsibility: hierarchy of the medical system, role definitions, evolution of responsibility, ownership of decisions for confidence building, quality and consequences of mentorship and personality traits upon admission.


We identified 6 potential barriers to the development of pharmacists' self-confidence and responsibility. These findings have practical applicability for educational research, future curriculum changes, experiential learning structure and pharmacy practice. Due to bias and the limitations of this form of exploratory research and small sample size, evidence should be interpreted cautiously.


Pharmacists feel neither responsible nor confident for their clinical decisions due to social, educational, experiential and personal reasons. Can Pharm J 2013;146:155-161.


Themes and supporting quotations from pharmacist interviews illustrating the six potential barriers (extracted from the paper):

Hierarchy of the medical system

Three participants directly acknowledged the hierarchical structure of the medical team as a barrier to gaining responsibility and confidence, and 2 others felt that “asking permission” for clinical decision making was necessary to make decisions. Pharmacists felt that they did not have a “place” in the hierarchy and therefore could not take responsibility for their patients. In addition, pharmacists did not feel responsible for their decisions due to the fact that pharmacists cannot prescribe.

Role definitions

Several participants voiced a concern that the public views the pharmacist as a “pill dispenser” rather than a clinical decision maker. Hospital pharmacists viewed their own role as “information gatherer and disseminator” versus responsible clinician. Participants felt the role of the pharmacist has not been clearly defined to the public or other health care professionals. Therefore, the educational background of the pharmacist goes unappreciated and unrecognized. Overall, role definition of clinical confidence and responsibility were characterized as underdeveloped.

Evolution of responsibility

By nearly unanimous response, pharmacists did not feel they were prepared for taking responsibility for their patients and were not confident in clinical decision making after their entry-to-practice education. Pharmacists who continued their education through a hospital residency, Doctor of Pharmacy degree program or through practical experience expressed an increased feeling of responsibility and confidence. Exposure to new and challenging situations that forced pharmacists into clinical decision-making activities built confidence and responsibility. Most pharmacists felt that the medical model of graduated responsibility through clerkship and residency with increased amounts of hands-on experience would better prepare pharmacy students for clinical practice.

Ownership and confidence building

Pharmacists commented that to build confidence, ownership of decision making and accountability for those decisions must take place. Until pharmacist prescribing is initiated, sense of ownership and responsibility will not thrive. In addition, several pharmacists suggested that faculty should be teaching and assessing accountability in pharmacy education. Participants thought that accountability for decisions would promote responsibility and clinical reasoning skills. Overall, pharmacists felt that knowledge, experience and continuous education contributed most to building confidence.

Quality and consequences of mentorship

The quality of mentorship received in the undergraduate pharmacy program was identified as a direct predictor of confidence and responsibility upon graduation. Pharmacists exposed to well-rounded mentors advocating for patient-centred care expressed increased confidence in their own decision-making abilities and willingness to approach greater responsibility. On the contrary, pharmacists who observed meek, hesitant, apologetic mentors learned self-doubt and indecisiveness.

Personality traits upon admission

Some participants stated that pharmacy and medical students are not similar at baseline. Some felt that pharmacy students are more likely to identify with absolute sciences rather than to take the “clinical side” of practice. Other participants acknowledged that pharmacists are reluctant to make decisions in clinical grey areas, whereas physicians are comfortable in these settings. It was hypothesized that this innate discomfort with ambiguity may be tempered by earlier introduction of clinical decision making in the pharmacy curriculum.

Professor Zubin touches on points I have described, particularly in ownership and confidence building, and the quality and consequences of mentorship.
Because of my mentors and management consultant training I have had no problem moving into a clinical role.
As far as personality traits are concerned, this is subjective.
Given the right environment where clinical pharmacists could be trained in a community pharmacy setting, attitudes could be rapidly changed as the confidence factor was improved.
One idea to resolve this may be to have a number of “training pharmacies” operating within the community setting and a system where established clinical pharmacy practices could siphon off pharmacists that passed through such a system.
As these pharmacists would be fee generators, they would virtually generate their own income with the more successful being partnered into a structured clinical practice.

Whatever your thoughts it is time to move on from the current community pharmacy model – so just get on with it!

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