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Hospital doctors' views of, collaborations with and expectations of clinical pharmacists
  1. Mohamed M M Abdel-Latif1,2
  1. 1Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt
  2. 2Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
  1. Correspondence to Dr Mohamed M M Abdel-Latif, Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut 71526, Egypt; abdel-latif{at}mailcity.com

Abstract

Objective The collaboration between doctors and clinical pharmacists is a key factor in the provision of drug therapy and the continuity of patient care. The aim of this study was to explore the views of hospital doctors on the clinical role of pharmacists, barriers to interaction with them and their expectations of them.

Methods A self-administered survey was conducted among a representative sample of doctors (n=400) recruited in hospitals in the Madinah region of Saudi Arabia; 270 surveys were returned, yielding a 67.5% response rate.

Key findings Most doctors knew about clinical pharmacy (85.19%), but only 42.96% of them were aware of the existence of clinical pharmacy services in their hospital. Nearly three-quarters of doctors (74.07%) were willing to collaborate with a clinical pharmacist despite existing barriers that hinder interprofessional collaboration. Approximately 67.78% of the doctors strongly agreed or agreed that a clinical pharmacist was a reliable source of drug information. The most common queries from doctors to pharmacists were about drug alternatives (46.29%), drug interactions (39.26%), drug availability (37.77%), side effects (34.81%), drug dosage (26.29%), drug indications (24.81%), drug costs (21.48%) or other (7.41%). Only 19.63% of respondents would always accept a pharmacist's modification to a prescription. Most of the doctors (70%) expected the clinical pharmacist to advise them on rational use of drugs, to resolve drug-related problems and to counsel patients.

Conclusions Doctors widely accept that clinical pharmacists can make a great contribution to the provision of drug therapy. However, strong interprofessional collaboration between doctors and clinical pharmacists is needed to optimise patient care.

  • CLINICAL PHARMACY
  • Clinical pharmacist
  • views
  • expectations

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EAHP Statement 4: Clinical Pharmacy Services

Introduction

The pharmacy profession has undergone significant changes over the last few years since the introduction of the concept of clinical pharmacy and the philosophy of pharmaceutical care.1 ,2 This concept necessitates the participation of a pharmacist in the pharmacotherapy plan and drug therapy decisions as well as collaboration with healthcare professionals. Today, the pharmacist's role has evolved to clinical involvement in the healthcare system to ensure that a patient achieves positive outcomes from drug therapy.3

Pharmacists have the capability to play a large role in the delivery of healthcare services to the healthcare team and patients. Several studies have reported that the functions and interventions provided by clinical pharmacists improve rational drug therapy and optimise health outcomes.3–6 These functions include medication therapy management, providing drug information, taking medication histories, patient counselling, providing disease-prevention services, selecting drug therapies and reporting adverse drug reactions. These services become valuable when a clinical pharmacist is included in the interdisciplinary healthcare team.7 ,8

Collaboration between doctors and pharmacists is necessary in order to fully utilise pharmacists' skills in managing drug therapy. The complexity of drug therapies, multiple drug regimens, medical malpractice and occurrence of medication errors means that close interaction between doctors and pharmacists is necessary to optimise drug therapy. Good collaboration between doctors and pharmacists has been shown to result in improved service delivery and enhanced patient outcomes.9 Furthermore, pharmacists have been successfully integrated into drug therapy management processes and patient care in clinical settings.10–13 Therefore, understanding the means of cooperation between doctors and pharmacists and ways to avoid barriers to effective collaboration may help with delivery of optimum healthcare services. There is evidence that the addition of a pharmacist to a collaborative, team-based setting can improve performance against quality indicators and national health goals.14 ,15

The role of the pharmacist in a healthcare team varies greatly from one country to another and from hospital to hospital, from dispensing and supplying of medicines to sharing pharmaceutical services with doctors and patients, depending on the healthcare system in each country and the healthcare providers.16–19 In countries such as Saudi Arabia, Kuwait, Qatar, United Arab Emirates, Egypt, Jordan, Palestine and Sudan, it was found that healthcare professionals' acceptance of the pharmacist’s role in clinical practice remains debatable.20–27 In Saudi Arabia, despite the concept of clinical pharmacy being well developed and practised to a certain extent in clinical settings, it still faces barriers such as shortage of clinical pharmacists and the ‘opponent’ image of pharmacists among doctors as members of the healthcare team. Doctors’ poor knowledge of the clinical role of pharmacists and the lack of communication between doctors and pharmacists could result in bad consequences for patients.

Clinical pharmacists working in Saudi hospitals can perform a number of functions such as providing drug information, dosage adjustment consultations, dispensing and administrative services, and patient education. Therefore, understanding doctors' views and expectations of pharmacists should improve cooperation between these professionals. The objectives of this study were to (1) examine the views of hospital doctors on the clinical role of pharmacists and (2) understand their expectations of the clinical pharmacist's role in patient care in Madinah hospitals in Saudi Arabia.

Methods

Study subjects

A cross-sectional study was conducted during the period January 2015 through June 2015 in Madinah, Saudi Arabia. The study was approved by the ethics committee of Taibah University. Clinical pharmacists in the Madinah region are engaged in dispensing and administration services, monitoring medication therapy, and providing drug information and patient education. The doctors were selected randomly from hospital lists (n=400) of eight government and private hospitals, and the questionnaire was distributed to doctors according to first-contact basis. Doctors' work positions included assistant hospital, registrar, senior registrar and consultant of several medical specialties such as medicine, surgery, cardiology, oncology, paediatrics, gynaecology, psychiatry and ophthalmology. Participation was voluntary and a consent form was obtained from all respondents. The participants were assured of anonymity and that their answers would remain confidential. They were also assured that the findings would not identify them and only the aggregate data would be reported.

Study design

A 35-item self-administered questionnaire was developed through an extensive literature review.20–27 A draft of the survey was piloted on a number of practising doctors (n=15) to check its clarity and content validity. On the basis of the results of this pilot study, the final questionnaire was used in the study. The final questionnaire consisted of five parts: the first part (seven questions) covered demographic characteristics such as gender, age, nationality, qualifications, current position, years of experience, and area of practice; the second part (five questions) comprised doctors' knowledge and views of clinical pharmacy and clinical pharmacists; the third part (five questions) addressed the opinions of the doctors on clinical pharmacists’ abilities to provide clinical services, drug information and drug therapy recommendations and ways of interacting with them; the fourth part (eight questions) included barriers to collaboration between doctors and clinical pharmacists; the fifth part (10 questions) dealt with doctors' expectations of the clinical pharmacist's role in hospitals.

Data analysis

The data from the questionnaires were computed and analysed using SPSS, V.15. Descriptive analysis was used, and the results of each item in the questionnaire were reported as number (%).

Results

Demographic characteristics of doctors

Of 400 hospital doctors surveyed, 270 (67.5%) participated, with male dominance (211 (78.15%)). The most common reasons for refusal to participate were unavailability or simply unwillingness. Most of the respondents were in the 30–39 and 40–49 year age ranges. Only 17 (6.29%) doctors possessed a postgraduate diploma, 77 (28.52%) had a masters degree, 94 (34.81%) had a doctor of medicine degree (MD), and 40 (14.82%) had a doctor of philosophy degree in medicine (PhD). Half of the respondents had a total experience of ≥10 years. Nine nationalities were represented: 135 (50%) Saudi nationals, 88 (32.59%) Egyptians, 19 (7.04%) Sudanese, 12 (4.44%) Pakistani, and 16 (5.93%) other. The specialisation (area of practice) varied greatly, with the largest being paediatrics (57 (21.11%)) followed by medicine (53 (19.63%)), surgery (37 (13.70%)), cardiology (27 (10.00%)) and other (96 (35.56%)). The demographic characteristics are presented in table 1.

Table 1

Demographic characteristics of the respondents (N=270)

Doctors’ knowledge of clinical pharmacy and clinical pharmacy services in hospitals

In this study, we noted that most doctors (230 (85.19%)) had good knowledge of the clinical pharmacy specialisation. However, only 116 (42.96%) were aware of the existence of clinical pharmacy services in their hospital (table 2). In answer to the question about the availability of a clinical pharmacist to provide clinical pharmacy services, only 145 (53.70%) doctors thought that clinical pharmacists were practically available to provide such services (table 2). About three-quarters (200 (74.07%)) of the doctors were willing to collaborate with clinical pharmacists in hospitals, and 224 (82.96%) believed that collaboration with clinical pharmacists can improve health outcomes.

Table 2

Doctors' knowledge of clinical pharmacy and collaboration with clinical pharmacists (N=270)

Frequency and methods of interaction between doctors and clinical pharmacists

We found that the frequency of interaction between doctors and clinical pharmacists was variable: 34 (12.59%) doctors had interactions with clinical pharmacists once a day or more, 61 (22.59%) once a week or more, 38 (14.07%) once a month or more, 72 (26.67%) rarely, and 65 (24.08%) never interacted with a clinical pharmacist (figure 1A). When doctors were asked about methods of contact with clinical pharmacists, it is notable that they used more than one method to contact clinical pharmacists for drug therapies and therapeutic plans: 135 (50%) doctor–pharmacist interactions were face-to-face, 98 (36.31%) by phone, 34 (12.59%) by paper, 23 (8.52%) by e-mail, and 8 (2.96%) by other means (figure 1B).

Figure 1

(A) Frequency of interaction of doctors with clinical pharmacists. (B) Ways doctors contact clinical pharmacists.

Clinical pharmacists as source of drug information

More than two-thirds of the doctors (183 (67.78%)) strongly agreed or agreed that clinical pharmacists were a reliable source of drug information (figure 2). The most common drug queries from doctors to clinical pharmacists were about drug alternatives (125 (46.29%)), drug interactions (106 (39.26%)), drug availability (102 (37.77%)), side effects (94 (34.81%)), drug dosage (71 (26.29%)), drug indications (67 (24.81%)), drug costs (58 (21.48%)) and other (20 (7.41%)) (figure 3). On assessing the acceptability to doctors of a clinical pharmacist modifying a prescription, 53 (19.63%) would always, 142 (52.59%) would sometimes, 57 (21.11%) would rarely and 18 (6.67%) would never accept a clinical pharmacist’s decision on appropriate medication (figure 4).

Figure 2

Doctors' opinions of clinical pharmacists as a reliable source of drug information.

Figure 3

Reasons for interaction of doctors with clinical pharmacists.

Figure 4

Acceptability to doctors of a clinical pharmacist's modification of a prescription.

Barriers to collaborative work between doctors and clinical pharmacists

Barriers to collaborative work between doctors and clinical pharmacists are shown in table 3. Doctors suggested that a shortage of competent clinical pharmacists in clinical settings (118 (43.70%)), lack of support for clinical pharmacy services from hospital administration (102 (37.78%)), lack of communication between doctors and pharmacists (98 (36.29%)), inadequate clinical knowledge of pharmacists (92 (34.07%)), lack of time (79 (29.26%)), lack of trust in clinical pharmacists' abilities (60 (22.22%)), lack of privacy for consultation (54 (20%)) and concern regarding confidentiality over shared patient information (44 (16.29%)) were the major obstacles to collaboration in hospitals.

Table 3

Barriers that doctors feel affect collaborative work with clinical pharmacists (N=270)

Doctors’ expectations of the job of the clinical pharmacist

Doctors' expectations of the clinical pharmacist role in hospitals were also assessed and are listed in table 4. More than 75% expected clinical pharmacists to provide them with drug information, to counsel patients about the safe and appropriate use of medications, to detect and prevent medication errors, to resolve drug-related problems, and to advise them on rational use of medicines. In addition, more than 65% of respondents were comfortable with the ability of clinical pharmacists to monitor prescribing patterns of doctors, assist in drug dosage adjustment, suggest use of non-prescription drugs to patients, and monitor drug therapy. About half (52.59% (142)) of responding doctors were comfortable with clinical pharmacists treating minor illnesses such as colds and headaches.

Table 4

Doctors’ expectations of the role of clinical pharmacists (N=270)

Discussion

In most developing countries, doctors may not recognise the scope of clinical pharmacy services and the role of clinical pharmacists in the provision of drug therapy to improve patient care and maximise healthcare outcomes. In this study, we explored the views, perceived barriers and expectations of doctors regarding clinical pharmacists and their roles in hospitals in the Madinah region of Saudi Arabia. The majority of hospital doctors were familiar with the clinical pharmacy specialisation, but they were unaware of the existence of clinical pharmacy services in their hospital. Hospital doctors were satisfied that clinical pharmacists were capable of providing clinical pharmacy services to evaluate and assess a patient's drug therapy and monitor the pharmacotherapeutic needs of the patient in order to ensure the appropriate and safe use of drugs. However, they indicated that clinical pharmacy is not practised in a uniform manner in many hospitals. In line with our results, physicians from countries such as Kuwait, Jordan, Sudan, United Emirates and Egypt appeared familiar with the clinical pharmacy profession, but they were sceptical about accepting the clinical roles of pharmacists.20–27

The function of clinical pharmacists in hospitals in many developing countries is limited to drug dispensing, procurement and inventory control.16–19 Doctors and pharmacists are perceived as opponents rather than members of the same healthcare team providing patient care in developing countries.28 The role of pharmacists is still underutilised in those countries, and this could be improved by increasing interprofessional communication between doctors and pharmacists in the healthcare system. Therefore, government policies and hospital administrators should encourage the doctor–pharmacist relationship to act as one team to deliver healthcare services and enhance the role of clinical pharmacists in primary care.

In this study, it is notable that doctor–pharmacist interactions were highly variable from one hospital to another, and a large number of doctors rarely or never interacted with clinical pharmacists. Hospital pharmacy is well developed in the Madinah region in the provision of dispensing, sterile compounding of drugs, drug information, monitoring, drug use evaluation and patient education. Such hospital pharmacies use new technologies such as bar-code technology, unit dose drug distribution systems and automated medication distribution; however, there is a lack of promotion of drug therapy monitoring, a lack of well-trained clinical pharmacists, and poor collaboration among the members of healthcare teams. Poor doctor–pharmacist collaboration may have a negative impact on the healthcare system and patient outcomes. Most doctors stated that they have some form of interaction with clinical pharmacists; face-to-face was the most common method of communication between them. Previous studies have reported the existence of a communication gap between pharmacists and doctors in clinical practice.29 ,30 Therefore, effective collaboration between doctors and clinical pharmacists forms the basis for assessing the appropriateness of drugs and sharing the responsibility for the safety of drug use.

There are numerous drug information resources available to doctors, and prescribing decisions are greatly dependent on the quality of drug information derived from these resources. Clinical pharmacists are educated to critically evaluate and assess the reliability of drug information. Therefore, the clinical pharmacist can serve as an excellent resource for drug information, particularly with respect to safety and efficacy. In this study, many doctors strongly agreed or agreed that the clinical pharmacist was a reliable source of drug information. The types of drug information commonly requested by doctors from clinical pharmacists involved drug alternatives, drug interactions, drug availability and side effects.

In this study, doctors expected that the clinical pharmacist could perform a wide range of clinical services, such as providing drug information, advising them on rational use of medicines, resolving drug-related problems, detecting and preventing medication errors, and counselling patients about the safe and appropriate use of drugs. The extended functions of clinical pharmacists in clinical settings have been well documented.31 ,32 Moreover, doctors expected clinical pharmacist advice regarding drug appropriateness and drug interactions, as well as help in the decision-making process based on drug efficacy and pricing in hospitals.33

In our study, a small percentage of doctors strongly agreed with clinical pharmacist modification of prescriptions and could accept pharmacist recommendations, but the majority were reluctant to accept a clinical pharmacist's decision to a change a prescription. It has been reported that pharmacist interventions can raise physician awareness of medication costs and quality and influence their prescribing habits.34 On the other hand, another study found that most physicians favour patient counselling by clinical pharmacists but are opposed to pharmacist prescribing.35 Therefore, clinical pharmacists could have a greater influence on doctors' decisions during the prescribing stage and treatment plan.

As doctors are busy with the diagnosis and treatment of patients, the clinical pharmacist can assist by selecting the most appropriate drug for a patient. Previous studies reported that physicians were comfortable with pharmacists detecting and preventing prescription errors, but were uncomfortable with them recommending drug therapy to patients.21 ,23 ,25–27 Acceptance of pharmacists' suggestions by prescribers is a necessary component of the evaluation of clinical pharmacy services. Klopfer and Einarso36 reported that factors leading to non-acceptance of pharmacists' suggestions by prescribers include a negative attitude to clinical pharmacy, the quality of the suggestions, communication obstacles between the pharmacist and the physician, and a lack of physician awareness of pharmacokinetic parameters. Therefore, clinical pharmacists need to work with doctors to identify the proper drug for the individual patient's need. Unfortunately, there are many obstacles to clinical pharmacists contributing to healthcare, including the low acceptance of the clinical role of clinical pharmacists by doctors, lack of communication between doctors and clinical pharmacists, lack of trust in clinical pharmacists' abilities to provide patient care, concern regarding confidentiality and privacy of patient information, and lack of support from hospital administration for collaborative work between doctors and clinical pharmacists.

Conclusion

Our study demonstrates that doctors know about the role of clinical pharmacists in providing clinical services in hospitals and they have high expectations of clinical pharmacists participating in the medication use process. Therefore, interprofessional collaboration between doctors and clinical pharmacists can greatly improve patient care and maximise healthcare outcomes. However, much effort is required to increase the awareness of doctors about the clinical merit of clinical pharmacy and the importance of collaborative work with clinical pharmacists in the provision of drug therapy and healthcare outcomes.

What this paper adds

  • What is already known on this subject?

  • The concept of clinical pharmacy is increasingly being recognised, but the role of the clinical pharmacist needs to be underpinned in many developing countries.

  • Clinical pharmacists are educated to perform a wide range of clinical services.

  • Doctors have infrequent interactions with clinical pharmacists in hospitals.

  • What this study adds?

  • Doctors appreciate the clinical role of clinical pharmacists in patient care, but their knowledge of clinical pharmacy practice in hospitals is limited.

  • Doctors agree that collaborative work with clinical pharmacists can optimise patient outcomes, but they cite a number of barriers to interaction with clinical pharmacists in hospitals.

  • Doctors should be educated about clinical pharmacists' roles, and effective policies for strong collaboration should be put in place in hospitals.

Acknowledgments

The author thanks all participants for their contributions to this study.

References

View Abstract

Footnotes

  • Competing interests None declared.

  • Ethics approval The study was approved by the ethics committee of Taibah University.

  • Provenance and peer review Not commissioned; externally peer reviewed.