Roxanna S D Mohammed, MD, BSc(Pharm), Eugene Y H Yeung, MD, MSc, ACPR, BSc(Pharm)
We read with interest Ricky Turgeon’s letter on physical examination of patients by pharmacists.1 Having both been pharmacists in the past, we support the performance of physical examination by pharmacists, and believe that examinations aid in the monitoring of drug therapies. With good clinical knowledge and examination skills, clinicians can reduce the need to order unnecessary tests, as recommended by Choosing Wisely Canada.2 We acknowledge the skepticism about pharmacists’ examination skills that is expressed by nurses and physicians, as described by Turgeon. From the perspective of our experience as physicians, we would like to share our opinions on how to bring pharmacists’ examination skills to a level on par with those of other health care professionals.
We would like to first comment on why others may be skeptical of pharmacists’ examination skills. One study showed that only 38% of Canadian pharmacists performed physical examinations in practice.3 Most of their examinations related to measuring blood pressure (48%), and a few involved assessments of patients’ feet, edema, and cuts (4%). Only 18% of the respondents stated that they had received formal training on physical examinations in the past. It is not surprising that other professionals have poor perceptions of pharmacists’ examination skills.
Videos and textbooks are available that allow pharmacists to develop a certain level of examination skills through self-directed studies. However, such skills can only be developed accurately and to a high level through hands-on practice. When we were in medical school, we examined patients on a routine basis, and were constantly evaluated in formative and summative assessments. In contrast, during our pharmacy training at a Canadian university, we spent no time examining patients.
This contrast between the medical and pharmacy curricula has led us to wonder how “formal training on physical examinations” is defined in pharmacy. In the aforementioned study of physical examination by pharmacists, participants reported feeling significantly more confident in doing examinations after only 2 hours of training.3 Ironically, though, their actual use of examinations remained unchanged 4 weeks after the training, which might lead to participants losing their skills.
One aspect of major concern to us is the legality of pharmacists’ examinations. In medicine, physicians learn how to respect patients’ modesty during examinations, and to offer chaperones when examinations are considered intimate. They are made aware of the slight risk of injuring patients when performing procedures without adequate training, and their medical insurance covers them for performing examinations. In contrast, does pharmacy insurance cover pharmacists when they perform examinations? When such matters are taken to court, the plaintiff can easily find an experienced pharmacist to be an expert witness and, through that witness’s testimony, raise questions about whether physical examinations are the norm in pharmacists’ practice.4 Many of the pharmacies we have visited in the course of our work as pharmacists and then physicians have not even had an examination bed in a private room. How can pharmacists ensure patients’ modesty and safety when examinations are performed in an inadequate setting?
It could be argued that the performance of examinations should be limited to hospital pharmacists, to the exclusion of community pharmacists, because hospitals have the facilities and insurance for practitioners to perform the relevant tasks. However, we do not agree with setting a double standard for hospital and community pharmacists. Community pharmacists are known as “the front line of health care”, and they represent the majority of pharmacists.5 It would not make sense to proclaim that all pharmacists can do examinations when the majority are not doing so. Practitioners, including physicians and pharmacists, must also be aware that hospital insurance typically covers the workplace, but not individual practitioners. In the event of lawsuits filed directly against practitioners, the practitioners must have their own liability insurance.
This article is not meant to discourage pharmacists from performing physical examinations, but rather to suggest ways to facilitate appropriate implementation of these skills into their clinical practice. First, pharmacy training for physical examinations needs further improvement. We acknowledge that the Doctor of Pharmacy programs are now putting more emphasis on examinations. However, many pharmacists currently in practice graduated without such training. Colleges of pharmacists should provide more supplemental training courses in this area, and should consider including examinations in the national objective structured clinical exam.6 The colleges should also consider offering accredited qualifications to pharmacists who have additional training on examinations, similar to pharmacists who perform intramuscular injections. This would legally cover pharmacists for performing examinations. Second, the physical layout of many pharmacies will need to be changed. If staff pharmacists opt to perform examinations, their workplaces should have an examination bed in a private room, along with basic equipment such as stethoscopes and tendon hammers. Third, pharmacists should explore opportunities to learn examination skills from other health care professionals. We acknowledge that pharmacists are very involved in the provision of medical education. Perhaps it is time for more professional sharing of skills and experience, which would benefit both professions.
In conclusion, we would like to borrow an old saying from our pharmacy training: “Practice does not make perfect—practising the right thing makes perfect.”
1 Turgeon RD. Physical assessment by pharmacists: a valued component of care [letter]. Can J Hosp Pharm. 2017;70(3):250–1.
2 Canadian Association of Pathologists; Canadian Society of Internal Medicine. Lab tests before surgery: when you need them and when you don’t. Toronto (ON): Choosing Wisely Canada; 2014 [cited 2017 Jul 15]. Available from: https://choosingwiselycanada.org/lab-tests-before-surgery/
3 Barry AR, McCarthy L, Nelson CL, Pearson GJ. An evaluation of teaching physical examination to pharmacists. Can Pharm J. 2012;145(4):174–9.e1.
4 Warning for pharmacist after inappropriate touching during examination in consultation room. Pharm J. 2012;288:122.
5 Gidman W, Day J, Hassell K, Payne K. Delivering health care through community pharmacies: are working conditions deterring female pharmacists’ participation? J Health Serv Res Policy. 2009;14(3):141–9.
6 Pharmacist-performed physical assessment. Vancouver (BC): College of Pharmacists of British Columbia; 2016 [cited 2017 Jul 15]. Available from: www.bcpharmacists.org/readlinks/guest-post-pharmacist-performed-physical-assessment
Competing interests: None declared. ( Return to Text )
Ricky D Turgeon, BSc(Pharm), ACPR, PharmD
[The author replies:]
I thank Roxanna Mohammed and Eugene Yeung for their interest in my letter, and for presenting pragmatic issues for discussion.
As pharmacists, we should acknowledge that any additional responsibilities we undertake as part of our scope of practice—including all the key clinical services that improve patient outcomes, such as administering parenteral medications, prescribing medications, and monitoring drug therapy by ordering and interpreting laboratory tests—exposes us to liability for damages. Physical assessment is no different, and in fact complements each of the above interventions. Several options are available for pharmacists seeking personal liability insurance, so individuals should familiarize themselves with the policies available to them.
I share the vision of all pharmacists employing physical assessment within their practice; however, proper training and hands-on practice must come first. In 2014, the National Association of Pharmacy Regulatory Authorities (NAPRA) included physical assessment as a key competency for Canadian pharmacists at entry to practice.1 In 2017, however, this is far from a standard in Canada; there must first be a sufficient number of pharmacists properly trained in physical assessment and using this skill routinely in practice before we have the necessary infrastructure in place to teach these skills to pharmacy students. I believe we are rapidly approaching this tipping point, with British Columbia leading the way. The Physical Assessment Course for Pharmacists offered by the British Columbia Branch of the Canadian Society of Hospital Pharmacists (CSHP) has provided physical assessment training to more than 200 practising community and hospital pharmacists across the province. This 30-hour, hands-on course with summative examination addresses various aspects of physical assessment, including how to approach patients to minimize discomfort and respect their modesty. Three institutional pharmacy colleagues and I recently published an article in this journal highlighting their success in integrating physical assessment into completely different practice settings after completion of this course.2 Pharmacists such as these can become local champions, solidifying physical assessment as an expected component of care and “part of the job description” at their sites, and offering guidance and training to colleagues and trainees. Once we establish this network of mentors for physical assessment by pharmacists, we can provide universal, reliable, practical training to learners. Such efforts are likely to start small, focusing first on advanced pharmacy learners such as postbaccalaureate Doctor of Pharmacy students and residents in collaborative institutional practices, later spreading as a standard component of every entry-to-practice curriculum as mentorship capacity increases.
Mohammed and Yeung propose that pharmacists should explore opportunities to learn physical assessment from other health care professionals. I wholeheartedly agree; in fact, this has been the approach of all the pharmacists I know who have successfully incorporated physical assessment into their practices. For example, during my own training, I participated in weekly bedside physical assessment teaching rounds with medical residents, whereby we would all take turns examining a patient (usually selected because of notable exam results) and describing our findings. Moreover, the CSHP BC Branch course is taught by a combination of physicians and pharmacists, who are able to provide learners with both professions’ perspectives on technique and interpretation. Furthermore, the 3 pharmacists profiled in the recent article all described how important their physician and nurse colleagues were in successfully implementing physical assessment and continuing to hone their skills.2
1 Professional competencies for Canadian pharmacists at entry to practice. Ottawa (ON): National Association of Pharmacy Regulatory Authorities; 2013.
2 Chua D, Ladha F, Pammett RT, Turgeon RD. Pharmacist performance of physical assessment: perspectives of clinical pharmacists working in different practice settings. Can J Hosp Pharm. 2017;70(4):305–8.
Competing interests: None declared. ( Return to Text )
Canadian Journal of Hospital Pharmacy, VOLUME 70, NUMBER 6, November-December 2017