Original ResearchExploring successful community pharmacist-physician collaborative working relationships using mixed methods
Introduction
The recent proliferation of medication therapy management (MTM) services offered through Medicare Part D1, 2 has put a spotlight on patient care opportunities for pharmacists, particularly those who practice in the community setting. Activities, such as community pharmacist-provided MTM and disease state management, are enhanced when an effective collaborative working relationship (CWR) exists between the pharmacist and the patient's physicians. The potential benefits of physicians and pharmacists working together have been documented.3, 4, 5, 6, 7 Nevertheless, community pharmacists struggle to establish relationships with physicians. Lounsbery et al surveyed 970 pharmacists from various outpatient practice settings regarding their agreement with potential barriers in providing MTM services and found that community pharmacists were more likely than pharmacists in other ambulatory settings to agree that establishing CWRs with physicians was a barrier to service provision.8
To assist practitioners and researchers interested in pharmacist collaborations, McDonough and Doucette have proposed a conceptual model for the development of pharmacist-physician CWRs (Fig. 1).9 The CWR model was synthesized from models of interpersonal relationships, business relationships, and collaborative care from nursing/physician relationships.10, 11, 12, 13, 14, 15 This framework illustrates how individual, context, and exchange characteristics influence movement along a collaboration continuum, from stage 0 (professional awareness) to stage 4 (commitment to the CWR).9 Individual characteristics are those specific to each collaborating professional, such as age and educational background. Context characteristics, such as the proximity of the professionals and shared organizational structures, are associated with the practice site of the collaborators. Exchanges are the personal interactions that occur between physicians and pharmacists.
Using the CWR model as a guide, Zillich et al demonstrated that, although select participant and contextual characteristics influenced relationship development, exchange characteristics are the principal drivers in the development of pharmacist-physician collaborations.16 In 2005, Zillich et al found that these exchanges can be grouped into 3 domains: relationship initiation, trustworthiness, and role specification.17 The extent of professional collaboration can be quantified through the administration of the Pharmacist-Physician Collaborative Index (PPCI), a 14-item Likert scale that measures collaboration within the 3 exchange domains.16, 17, 18 This quantitative measure, however, does not reveal the specific exchanges that have occurred to reach a high level of collaboration.
The purpose of the present study was to describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using the aforementioned conceptual model and tool for quantifying the extent of collaboration among the professionals as guides. Insights from this study may assist researchers interested in understanding collaborative care models and pharmacists interested in developing collaborations in their practice, while further validating the CWR model proposed by McDonough and Doucette.9 To the authors' knowledge, this is the first study to explore, quantitatively and qualitatively, the professional exchanges occurring among pairs of community pharmacists and physicians engaged in highly CWRs.
Section snippets
Study design and participant recruitment
The first step in studying the professional exchanges occurring among highly collaborative pharmacist-physician pairs is to identify examples of these pairs to serve as research participants. In qualitative research, participants are selected for their familiarity with the concept in question19—in this example, the professional exchanges that have led to successful collaborations. Therefore, a nonrandom, purposeful sampling technique was used for participant identification and recruitment.19 In
Sample
There were 87 identified pharmacists representing a minimum of 29 states and Puerto Rico. Of these identified pharmacists, 24 provided consent and completed the online survey tools. Ten of these pharmacists were excluded, because they did not practice in a traditional community setting. Two pharmacists were excluded for incorrectly completing the survey tools (eg, not providing the name of a physician colleague). Two pharmacists did not respond to the request for participation in the
Discussion
The process for identifying community pharmacist-physician pairs engaged in effective CWRs was fruitful. Despite not providing experts with a clear case definition of “effective” or “successful,” the pharmacist PPCI scores were comparable with the highest scores reported in earlier studies, indicating high levels of collaboration among the identified sample.18 In addition, the physicians' PPCI scores were higher across each domain compared with previously reported scores among a large,
Limitations
This study had a relatively low response rate; 26% of the “experts” responded to the request for pharmacist identification, and fewer physicians than pharmacists agreed to participate in the online surveys and interviews. This may be because of “expert” misinterpretation of study-inclusion criteria. For example, the first author received several e-mails from “experts” stating that they could not identify a pharmacist, because the state they reside in does not allow legal collaborative practice
Conclusion
The study findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. It was observed that relationships appeared to develop in a manner consistent with the CWR model, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on
Acknowledgments
The authors would like to acknowledge Brittany DeVoge, Pharm.D., Gladys Garcia, Pharm.D., and Cheri Hill for assistance with data collection and management; Lois Edmondston for assistance with tables and figures; and the American Pharmacists Association Foundation and the Community Pharmacy Foundation for grant support.
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Financial Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employments, gifts, stock, holdings, or honoraria.
Funding: This study was supported by the American Pharmacists Association Foundation and the Community Pharmacy Foundation. Also, Dr. Zillich was supported by a Research Career Development grant from the Veterans' Affairs Health Services Research and Development (#RCD 06-304-1).
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At the time of this research, Dr Snyder was Community Practice Resident at the University of Pittsburgh School of Pharmacy, and Ms. Rice was M.P.H. Candidate at the University of Pittsburgh Graduate School of Public Health and Research Associate, University of Pittsburgh School of Pharmacy.