Partisan Control of Information: A Look at Pharmacy Practice Research

Canadian Pharmacists Journal (CPJ) is the official publication of the Canadian Pharmacists Association (CPhA).ⁱ It’s the only major journal publishing original pharmacy practice research in Canada that I’m aware of, and it’s also a good source of therapeutic information, including clinical practice guidelines (or their summaries) and clinical tools providing practical information that can be readily employed and referenced when providing patient care.¹ I started reading the journal regularly several years ago, prizing it mostly for its therapeutic articles but also because of insight its authors provide on professional practice issues.ⁱⁱ While I continue to read the journal for these reasons, there was a point where I began to distrust some of what I was reading. My initial concerns stemmed from the editorials, when I began to notice in their content echoes of the arguments that my “mentors” had only recently been employing to influence me to practise toward their self-serving ends.ⁱⁱⁱ Because of this, I started to take a more critical eye to much of what I read in CPJ. Not only did it become clear to me that there was reason for my concern, but I slowly understood that what I was seeing extended well below the editorials, into the commentary pieces, and even into the practice research itself. What took shape was a distorting of information, a bias that serves partisan ends,^iv forming the foundation of an education made to build individuals with misshapen and constrained ways of thinking that can be directed toward partisan goals, as described last month.² While I understand that this may come across as something of an outrageous (or inflammatory) claim from the outset, we can judge its true nature by analyzing multiple years of CPJ issues from this perspective.^v

The current editor-in-chief of CPJ is Ross T. Tsuyuki, who held that position in all of the issues I read for this essay,^vi and so a great deal of what I discuss will concern articles written by him. Another important thing co-written by Tsuyuki in 2015 is instructive in this analysis: a chapter on change management in the textbook, Pharmacy Management in Canada.³ The chapter outlines a model for change management that the authors employ to explain how to guide change initiatives within the profession. It gives us a good starting point for the greater analysis; because it does a lot to explain much of what Tsuyuki is attempting in his editorials, it can serve to give our discussion some direction.

The chapter starts by providing examples of companies whose success or lack thereof had to do with their ability to adapt to changing environments.^vii This relates to pharmacy, as pharmacy leaders have been arguing since the 1960s “that the long-term sustainability of the profession rests on its ability, and willingness, to assume responsibility for drug therapy management and outcomes,” but, in spite of this, “evidence suggests that pharmacy practice is still largely drug distribution-centred, as the majority of its practitioners view drug distribution as their primary responsibility.” The authors explain that change is difficult but inevitable, and they present a path to follow to effectively manage change within the profession by explaining the 8 steps of the change management model put forward by John Kotter in 1995, discussing each step in turn and in greater detail for the rest of the chapter.⁴

The first step is to establish a sense of urgency, such that “the status quo is no longer comfortable”—a required step, as “individuals and groups rarely engage in a change process without a compelling reason.” The authors discuss reasons pharmacists may not feel this urgency: members of the profession are held in high esteem; market demands are resulting in rising salaries and many employment opportunities; and the vast majority of Canadian pharmacies are profitable. Then, they bring up existing pressures that may cause this urgency: changes to laws could hurt pharmacies’ bottom lines^viii and other professions will be able to perform traditional roles that were previously almost solely the purview of pharmacists, going into the expanding roles of pharmacy technicians.^ix With this in mind, the authors make the case that “it appears now, perhaps more than at any other time in the past, that there is an urgent need for pharmacists to transition their practices.”⁵

The second step is to form a powerful guiding coalition, while the third is to create a vision. With regard to both steps, the authors note that “planned change, intended to achieve a desired outcome, is most likely to occur when a group of influential individuals come together to lead the change effort,” and that “without a clearly articulated vision, change efforts can become unfocused, unhelpful or even counterproductive in achieving the intended change.” CPhA’s efforts were said to be instrumental in driving both steps in the contemporary practice environment. The association “originally spearheaded the development of a guiding coalition that included representation from all sectors of the profession.” This process led to the Blueprint for Pharmacy initiative, in the mid-2000s, and the authors point to the Blueprint coalition’s strategic statement as this “clearly articulated vision,” which “outlined, in broad terms, the profession’s overall goals and objectives.”^6,x,xi

Step four is to communicate the vision, and this appears to be where the strategic plan behind Tsuyuki’s editorials begins to take shape. This step “involves the commitment of substantial resources and effort to ensuring the vision is being effectively communicated to those who will be involved in implementing the change, as well as those who will be impacted by the change.” Inadequate communication of the vision is said to be one of the key barriers previously noted to practice change within the profession and some examples are provided to show that this is still a problem.^xii The authors suggest that “pharmacists need more specific operational plans about what new pharmacy practice models might look like, what impact the changes would have on individual practitioners and how pharmacy team members could deal with those impacts,” and they point to the use of “pharmacist practice change stories” as a “powerful” approach, because “they allow individuals to make sense of their experiences and provide insight to others who can use those vicarious experiences to make sense of their own situations.”⁷

Step five is to empower others to act on the vision, which “involves removing obstacles to change and encouraging risk-taking.” This step is likely the most relevant to our discussion, as we’ll come to see that it appears to form the basis of the CPJ partisan strategy, with other steps effectively supporting this one. The authors note that “resistance to change may in fact be a symptom of systemic barriers not being removed, rather than individual resistance,”^xiii and they suggest that full engagement by change leaders is required, as people are unlikely to follow those who are recognizably all talk. “Barriers to practice change within pharmacy have been well documented and include lack of time, payment for clinical services and support from employers and other practitioners.” As such, some initiatives are aimed at removing some of these barriers,^xiv which should help, but “it is also not sufficient.” Focus is then placed on pharmacist culture, discussing the importance of having an “understanding of the practice context, including professional culture.”⁸ The authors don’t go into detail about why this is important, but there are at least two ways this can be viewed, either optimistically or cynically: (1) Developing a true understanding of the very real situation in pharmacies will provide better understanding about what really needs to be done to effectively enable and empower pharmacists; or (2) A deeper understanding of pharmacist perspectives better allows a propagandist to convince targets that they are being empowered without enacting necessary changes that are undesirable to influential stakeholders within a coalition.^xv Because the authors specify that “[f]uture work should include an in-depth examination of how pharmacists understand and internalize new practice opportunities, as well as how these opportunities are understood by organizations employing pharmacists”⁸—because they focus on pharmacist understanding and perception of “new practice opportunities” rather than relying on pharmacist insight to help identify tangible issues that could exist within the practice environment or within the “opportunities” themselves—I suspect the authors originally intended here to persuade rather than problem-solve.

The sixth step is to plan for and create short-term wins, which “allows group members to observe improvements and be encouraged to continue the change process.” Here, the authors focus on the provision of “regular positive messages reinforcing the vision and the change,” adding that such messages “support and validate the change process.” This relates to step seven, which is to consolidate improvements and produce still more change. For this step, “short-term wins are placed into the overall context of the change process so that members can see how the larger vision is being achieved through these successive small wins,” which “encourages individuals to continue with the change process.” To accomplish this, the authors recommend widely publicizing and celebrating changes to regulations and scopes of practice that are in line with the vision. And the eighth and final step entails institutionalizing new approaches, meaning that once changes are “fully integrated into the day-to-day operations of the group,” “[t]he emphasis now transitions from trying new approaches to embedding those changes as components of the group’s culture.” As an example, the authors explain how integration of pharmacy technicians in roles traditionally reserved for pharmacists helps secure the transition of pharmacists from drug distribution to clinical practice.⁹

The chapter concludes with repetition that “[i]mplementing change is indeed a challenge, but change cannot be avoided.” The authors explain that using a structured approach, like the Kotter model, allows us to manage the change process and proactively maximize positive outcomes while minimizing the negative ones, adding that “[w]hile change can be intimidating, successful change will allow the pharmacy profession to achieve its ultimate goal of providing better patient care.”¹⁰

With this as a rough guide, we can begin our discussion of CPJ articles. I want to start with the editorial in the Jul/Aug 2018 issue,¹¹ which is interesting to me from a propaganda standpoint. The editorial serves to address objections to expansion of the scope of pharmacy practice, largely coming from physician groups, in order to help pharmacists and pharmacy organizations respond in a way that’s less “weak.” The tone of the piece is belittling and sarcastic, which helps tactically to shut down opposition, either in addition to real arguments or in their absence, largely by presenting opposing arguments as ignorant or shameful (even where they may touch on valid concerns), thereby helping to shame and silence those influenced by the author^xvi who may actually believe in similar arguments.

The first argument discussed is that of fragmentation of care, which asserts that getting care from a healthcare practitioner who isn’t the primary physician could lead to discontinuity of care, contrary care decisions, or conflicting messages from different healthcare providers. Tsuyuki’s answer to this is that: (1) All jurisdictions require communication with physicians when interventions take place (and he throws the point back in physicians’ faces by suggesting that communication fails to flow in the opposite direction); and (2) A sizeable percentage of patients with chronic diseases do not see a family physician, meaning that this population hugely needs pharmacist interventions and that those lacking any care will not result in fragmented care. For both points, I agree, although some nuance of my thoughts here is worth mentioning. Though communication from pharmacists to physicians is required for expanded scope services, I have witnessed multiple instances, in multiple workplaces, where the pharmacist neglected to inform the primary or prescribing physician that a service was performed, including during pharmacist renewals or adaptations of prescriptions,^xvii meaning that such a point likely doesn’t fully answer this concern. And, while I believe that communication from the physician to the pharmacist is relevant to this argument—that a physician neglecting to communicate effectively with pharmacists has the potential to lead to conflicting messages, for example, even where traditional services, such as prescription counselling, are concerned—the way Tsuyuki makes this point is unhelpful. Presenting it accusingly as he does likely better serves to make the accuser double down on their belief than to convince them.

The second argument against expanded scope is the suggestion that pharmacists “do not have the training to assess patients, determine their needs and, gasp, make decisions.”^xviii To this, it is suggested that: (1) Pharmacy schools provide reasonable, basic training; (2) “[P]harmacists have superior knowledge about drugs and therapeutics” (and “[e]ven physicians would admit” this); (3) “Pharmacists are, by nature, systematic and like to base their decisions on evidence,” meaning “we actually read and follow clinical practice guidelines” (giving the example that “almost all” pharmacy undergraduate programs teach the Hypertension Canada guidelines); and (4) “Pharmacists are also cautious,” which means we have good sense that prevents us from working outside of our competencies. Though Tsuyuki appears quite confident in these assertions,^xix I agree with them far less than those from his previous argument. Firstly, although I understand the reputation that has been widely cultivated that “pharmacists have superior knowledge about drugs and therapeutics” than physicians, I don’t believe that this is necessarily the case and I doubt that it’s quite so simple.^xx Secondly, do pharmacists commonly “base their decisions on evidence”? Sometimes, certainly, but I’ve seen and heard enough during my time in this profession to believe that there are more than some pharmacists who lack understanding of important evidence when making decisions and providing information—and future articles in CPJ seem to agree with this suggestion, including those written by Tsuyuki.^xxi Thirdly, while I’d agree that pharmacists are generally cautious—perhaps even on the side of a bit too risk-averse—I have also felt pressured at work to practise in ways that felt uncomfortable and beyond my knowledge or abilities, and I find it hard to imagine that I’m the only one.

The third argument addressed is that of the potential conflict of interest when a pharmacist is both prescribing and dispensing. Here, Tsuyuki argues that: (1) We put the patient’s needs first, and we prove this by signing an oath that binds us to these principles, “[s]o to suggest that pharmacists would do otherwise is, frankly, insulting;” (2) To make such a claim is hypocritical, because we don’t worry about similar claims within other professions (including physicians or dentists who assess patients and decide whether they should go ahead with procedures the same practitioners then profit from); and (3) “[T]his allegation also assumes that we are foisting care upon the unsuspecting public, but they often ask for help from the pharmacist” (ending with the question: “Is it wrong to provide what the patient wants (and needs)?”). I, personally, do worry about this specific charge more than the others discussed, mainly because I’ve witnessed and experienced a great deal of business pressure and work tied to different expanded scope metrics leading to what I previously described as predatory practices where we try to extract more money from an unsuspecting public.^xxii

Tsuyuki then explains that “none of the objections refer to evidence for pharmacist care,” noting that “we have solid evidence for pharmacist care and advanced scope of practice,” and he once more throws this back in the faces of physicians with a suggestion that physician care lacks similar evidence. He cites a number of studies that support his claims here, including multiple studies that we’ll come back to shortly when discussing the partisan bias that exists within the practice research itself.^12,13 After this, Tsuyuki brings up other “comments that are circulated [which] are so repugnant and unprofessional that they are not worthy of a response,” such as: (1) “If pharmacists want to prescribe, they should become doctors;” (2) “It jeopardizes the doctor-patient relationship;” and (3) “Collaborative teams are fine, but must be led by a physician.” To this, it’s just suggested that it makes “one wonder what the real motivations are for opposing pharmacists’ scope of practice.” Even though I see these concerns as oversimplified and ignorant, I don’t necessarily see them as being so bad as Tsuyuki’s portraying them here, and I feel that they’re still touching on parts of real issues that are likely worthwhile to talk about. One example of a real point of discussion could be that certain interactions with the pharmacist have the potential to erode a patient’s trust in their physician; an important related question could be if we run the risk of causing this more frequently if we empower pharmacists. Another example could be to question if pharmacists commonly lack the skills to direct interdisciplinary care for patients, and to ask if physicians are better suited to do so. If there’s truth to both of these questions, what would need to be done to address such a skill-gap? Tsuyuki’s approach is dismissive of comments that actually could help us see real issues and, perhaps, confront them.

Tsuyuki concludes his editorial by suggesting that “[t]his is a profession-defining moment.” He then calls for unified action, advising that we “set the record straight,” and that “[w]e should ‘take the high road’—be firm, professional, respectful and evidence based,”^xxiii adding that we do also have support from outside the profession. He then reminds us that change is difficult but that we can’t avoid it, that we aren’t beholden to physicians, but rather to “our regulatory authorities and our patients and public,” and closes by saying, “Let’s not forget the importance of advancing pharmacy practice … because this is important for our patients and public health.”

I offered my perspective while outlining this article in order to both suggest that the criticisms that Tsuyuki belittles here may have more substance than they appear to have based on his portrayal and show that his arguments may frequently fail to actually answer such criticisms. Seeing things from this angle, what are we left with, a superficial tactic that helps to silence opposition? Probably, in part, but there’s also a deeper issue with this sort of editorial: that it serves to inflame existing partisan sentiment. If you view yourself as part of the partisan group, hearing arguments that portray the group in a negative light can already feel threatening, but the feeling gets worse when these arguments are portrayed as simply ignorant and inflammatory.^xxiv This grows the “us vs. them” mentality, widening the already present view of the partisan that the group is inherently good and others (especially “competitors”) are not.^xxv This blinds us to potentially important criticisms that could mean the difference between truly helping our patients and simply telling ourselves that we are.^xxvi-xxviii

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Partisan mentality blinds us to the truth not just because it blinds us to important criticisms that better allow us to see the truth. It biases the way we conduct research, the way we analyze data, and the way we interpret results. It becomes easier to do each uncritically when things agree with the underlying partisan view, and the editorial in the Sep/Oct 2020 CPJ provides an excellent source for further discussion in order to begin to show this.¹⁴ Tsuyuki wrote this article shortly after becoming the president of Hypertension Canada, and he offered some reflections on the importance of hypertension management and the opportunities available to the profession in this regard. He brings up statistics about the prevalence of the condition and the risk it presents as “the single most important preventable risk factor for premature morbidity and mortality.” He goes on to suggest that “[t]here is robust evidence for pharmacist care in hypertension—better evidence than for any other profession,” and adds that “[p]harmacist care in hypertension is cost saving—an estimated savings of $15.7 billion, even if only modestly implemented.” Tsuyuki then presents the case that control of blood pressure is worsening, necessitating refocusing, reengaging, and better treating these patients. And he describes how chronic disease care has suffered as focus has centred on the pandemic, but stresses that pharmacists are accessible and have the ability to make a difference. Tsuyuki ends with the promotion of the Hypertension Canada Professional Certification Program, which can “provide pharmacists with the knowledge and confidence to manage patients with hypertension.”

While the general messages about the importance of managing hypertension and pharmacists’ potential to intervene effectively here to help their patients strike me as straightforward and uncontroversial, there are important reasons to critically evaluate the studies referenced in support of them, along with the ways we interpret them. The first of three studies referenced here is a meta-analysis by Santschi et al. that investigated 39 randomized controlled trials assessing the effect of pharmacist interventions on blood pressure among outpatients, demonstrating a greater mean reduction in blood pressure with pharmacist intervention when compared against usual care (reporting systolic and diastolic blood pressure reductions of 7.6 and 3.9 mm Hg, respectively).^15,xxix Though the results of the study were statistically significant, an important flaw that should frame our interpretation of such results was the noted between-study heterogeneity, which suggests that the studies that were compared to come to these values may not have been truly comparable—that there was a lack of consistency of effects across the studies, which means that the results determined cannot be generalized and are, thus, unhelpful when describing the effect of pharmacist interventions, despite what otherwise appears to be strong results.^xxx This point was acknowledged within the discussion of the Santschi study, with the authors noting that “wide prediction intervals were observed, suggesting differential effects of pharmacist interventions on [blood pressure] in individual studies, from a very large effect to modest or no effect.” And the authors admitted that the study failed to identify precisely what components or aspects of the intervention led to more effective blood pressure control. Although the authors note that determinants of between-study heterogeneity could not be found, they add that the answer may lie in the data analyzed including a combination of pharmacist care in both community and clinical settings, with the implication that community-based interventions may prove to be less effective than those in outpatient clinics or medical groups, for example.^xxxi Therefore, the results of this study cannot in clear conscience be used to demonstrate the effectiveness of pharmacist interventions, especially so for interventions within the community setting.

The second study referenced in the editorial as an example of strong evidence for pharmacist care in hypertension management is a randomized control trial by Tsuyuki et al. that compared “enhanced pharmacist care” against usual care.¹² In the six-month-long study, all patients “received a wallet card for recording [blood pressure], lifestyle advice as required, [and] written information on cardiovascular disease.” Otherwise, patients in the usual care arm had their blood pressure measured every 3 months and were provided education at the discretion of each pharmacist. In comparison, the enhanced care group had “pharmacist assessment of and counseling about cardiovascular risk and [blood pressure] control, review of antihypertensive medications, and prescribing/titrating of drug therapy if deemed necessary.” These patients “were followed up at monthly intervals until their [blood pressure] was at target for 2 consecutive visits and thereafter at 3-month intervals for the duration of the study period.” All participating pharmacists “received training in [blood pressure] assessment and treatment that was based on the Canadian Hypertension Education Program (CHEP) guidelines and had access to hypertension experts for consultation as required,” but pharmacists in the enhanced care arm were also paid for their services.^xxxii The study found that their enhanced pharmacist care resulted in a mean reduction of systolic blood pressure at 6 months of 18.3 mm Hg, as compared to 11.8 mm Hg in the control group (an adjusted difference of 6.6 mm Hg). While I found no problems with the statistical analysis or the results of this study, I question how well its results can be generalized to existing models of care. Perhaps this view comes from my limited experience, but I haven’t witnessed or worked in pharmacies that provide adequate time for pharmacists to assess, counsel, and review medications thoroughly, support monthly follow up visits for more than a small number of patients, or provide “access to hypertension experts for consultation.” And I question how much benefit remains if we discard or reduce components from the intensive intervention described.^xxxiii I think that this study supports the potential that pharmacists have for improving the health of their patients,^xxxiv but I don’t view it as demonstrating the benefit of common pharmacist interventions.

The third study referenced in support of the “robust evidence” for pharmacist care is a cost-effectiveness study by Marra et al.,^13,xxxv and it’s the most problematic from my point of view. I can’t stress enough that the results and conclusions of this study should be interpreted extremely cautiously. The authors employ a cost-savings model based on the results of the two aforementioned studies.^12,15 Because of the significant heterogeneity and our inability to generalize the results of the Santschi study, the mean systolic decrease found (7.6 mm Hg) is likely to be severely limited in how instructive it can be to determine cost-effectiveness for pharmacist interventions. And, even though I would already suggest something similar about the Tsuyuki study—that it’s not reflective of real-world practice and is, thus, unhelpful if we truly wish to determine the cost-effectiveness of actual pharmacist interventions—this point becomes irrelevant in the context of the study. This is because the authors use the mean systolic decrease of 18.3 mm Hg from the intervention group of the Tsuyuki study rather than the adjusted difference when compared to the decrease found in the control group (6.6 mm Hg). The authors rationalize this because “the ‘control’ arm did receive a modified intervention, so is not a true reflection of outcomes under actual usual care, and these results were thus not felt to be an appropriate description of actual usual care with no intervention.” However, this equates usual care with no care, and comparing pharmacist intervention against no care instead of usual care makes this cost-effectiveness model arguably useless. On top of everything, we can take the mean systolic reductions of both studies at face value and the Marra study still demonstrates that they do not result in savings. This is because the authors also modelled systolic blood pressure reductions from 5 mm Hg up to 20 mm Hg. With this model, the costs of the intervention were found to be greater than medical cost offsets until a reduction of at least 10 mm Hg was reached—something that neither study that informed the model demonstrated. All this goes to “support” Tsuyuki’s assertion in his editorial that “[p]harmacist care in hypertension is cost saving.”¹⁴

After this critical re-evaluation of these studies, it’s important to similarly re-evaluate the statements they’re used to support. We’ve already seen multiple suggestions—in the Jul/Aug 2018 and Sep/Oct 2020 editorials, which both reference these studies—that pharmacist care is supported by better evidence than other professions have in their favour.^11,14 Upon closer scrutiny of this evidence, is this a fair claim? These studies also resurface periodically to support other arguments. The Jan/Feb 2020 CPJ editorial, for example, contains an argument in favour of pushing for “fair remuneration for pharmacists to manage hypertension,” claiming that it “should be the number 1 priority of our advocacy partners” as an issue to push with health policy makers.¹⁶ Here, the three above studies are referenced to show that “pharmacist care improves hypertension outcomes” and “saves money for the health care system,” going on to claim that “it is very clear that society would benefit from pharmacists practising to their full scope to detect and manage hypertension,” but that “remuneration systems have not kept pace to allow full implementation.” To this, we should likely question both if hypertension management by the pharmacist provides such a clear benefit and if it’s worthwhile for health policy makers to pay for such services. The Nov/Dec 2018 editorial also contains a similar argument, citing the Santschi study as an example of “the highest level of evidence,” and pointing to its results as “a compelling finding that should be implemented” as a service that should receive funding.¹⁷ My evaluation of the Santschi study provides a completely different context for the suggestion Tsuyuki makes in this editorial that when pharmacists, pharmacy organizations and policy-makers are evidence-illiterate, it “hurts us as a profession, and, by extension, does not serve our patients and society well.”

Once we begin to see problems in the portrayal of this evidence and the specific arguments it’s used to support, more general, problematic arguments begin to come into focus, but they only present themselves with the reading of CPJ over a longer period. One such argument that is developed over a multi-year period involves pharmacists’ understanding of and use of therapeutic and practice evidence, and we can look to three editorials to explain it. The first is the Nov/Dec 2018 editorial, which makes the case for the importance of evidence literacy for “pharmacists, pharmacy organizations and policymakers.”¹⁷ (As we’ve already critiqued what I view as the main issue with this article—that poor evidence is promoted as good evidence while making a claim in support of a partisan goal—I won’t dwell on it longer here.) The second article that concerns us here is the Mar/Apr 2021 editorial, which explains the importance for pharmacists to combat misinformation and disinformation.^18,xxxvi In this article, the authors explain that the majority of the public is unable to effectively differentiate between mis/disinformation and facts, and they go on to suggest that “[a]s pharmacists, we have the responsibility to speak up and dispel health mis/disinformation, especially around medicines,” and in the context of the pandemic. From here, tips from the World Health Organization—“adapted for a health context”—are provided to help address misinformation: (1) Identify the source of information, and don’t simply trust that a source will share factual information just because they have done so in the past; (2) Assess our biases, being conscious of when they may cloud our care decisions; (3) Check the publication date and use health resources that are frequently updating their info; and (4) Do your own research. For the final point, the authors suggest that databases that have critically appraised the evidence, such as Cochrane Library or UpToDate, are the best kinds of sources, adding that “[p]rofessional organizations are also trusted sources of information (e.g. Canadian Pharmacists Association).” With this, the authors “call for pharmacists to be good stewards of health information and actively participate in their vital role of combating mis/disinformation,” especially with regard to information regarding COVID-19 vaccines.¹⁹ Before continuing, I believe it’s important to make the point that I view the content of this editorial as objectively fair, but a more nuanced implication presents itself upon further consideration. The very act of publishing such an article supposes that CPJ will hold up as a bastion of unbiased “facts” under such scrutiny.^xxxvii And this idea is supported by overtly presenting CPhA as a trustworthy source, with a reminder to readers that “CPJ is the official publication of CPhA.”¹

The third article that will help bring this idea into perspective is the guest editorial published in the Mar/Apr 2022 CPJ.^20,xxxviii After defining mis/disinformation, the authors explain the expectations for practitioners of regulated health professions, along with “the consequences of the continued spread of COVID-19-related mis/disinformation,” including “serious harm and death,” and prolonging the pandemic. This builds to the suggestion that regulators must “take a clear stand against clinicians spreading mis/disinformation,” adding that it’s the duty of “pharmacists and other clinicians” to do this as well—here, citing the Mar/Apr 2021 CPJ editorial.¹⁸ Though “[a]t the time of writing, there have been no published disciplinary cases against Canadian pharmacists for behaviour related to COVID-19,” they go on to describe cases involving both pharmacists in other countries and Canadian physicians—although mention is made about the potential ineffectiveness of the action against the physicians.^xxxix The authors move to a discussion about the right to freedom of expression, which “is protected under the Charter of Rights and Freedoms,” but they add that this doesn’t allow people to spread disinformation. With regard to the latter point, they repeat the message from the College of Physicians and Surgeons of Ontario that “statements from a health professional, including social media posts, must be evidence-based,” further explaining that “[t]he onus is even greater when a health professional’s statements reach the public,” because such mis/disinformation can be “interpreted as medical advice by the general public” when the source presents it with the authority of a healthcare practitioner. After providing additional statements of this nature, the authors suggest that pharmacists who spread mis/disinformation “pose harm to the patient and to society and may be viewed by regulators as practising below the standard of clinical competence.” In conclusion, they add that, “[a]s a self-regulating profession, pharmacy regulators must act quickly to quash the spread of disinformation by pharmacists and must sanction decisively to denounce and deter this behaviour.”

Though I feel that the examples given in the Mar/Apr 2022 editorial are likely things the majority of pharmacists can agree crossed a line into unacceptable behaviour,^xxxix I worry about the one-sided nature of this editorial—that the authors don’t discuss the existence of this line, instead presenting “unacceptable practice” as a black-and-white thing even though not all of us would always agree upon where, precisely, practice crosses into something unacceptable—and I worry about the precedent this sets within the profession without a fuller, thoughtful discussion about the problem. My main concerns involve what truly constitutes mis/disinformation as compared to facts, how a publication like CPJ influences the way we view this problem, and if this can lead to poor practice through the punishment of disobedient pharmacists by our regulators. The three editorials discussed show a concerning progression in action, on one side building from the idea that pharmacists should be evidence-based in their practice and advocacy, to the idea that they should actively combat mis/disinformation, to the idea that regulators should be encouraged and empowered to punish pharmacists who are viewed as engaging in the provision of mis/disinformation. On the other side, promoting a source of demonstrably biased information as a source of facts, while working to define unacceptable practice that should presumably be punished. The best example I can provide to explain these concerns more specifically involves the Canadian national consensus guidelines for naloxone prescribing by pharmacists.²¹ After CPJ first published the guidelines in their Nov/Dec 2020 issue, there has been an apparent attempt by its authors to promote them and better establish them in pharmacy culture, with the Sep/Oct 2021 editorial repeating statistics given in the original document along with its recommendation that “all patients receiving a prescription opioid should receive a naloxone kit,”²² which are repeated again in a student article in the Jul/Aug 2022 issue,²³ and multiple naloxone FAQ articles have been published in their support.^24-26 I have significant criticisms of the guidelines that all these supporting articles fail to answer,^xL and what I criticize largely comes together to once more support what I previously described as predatory practices where pharmacists try to extract more money from an unsuspecting public.^xxii But does it matter if I believe that I’m providing my patients with better care when I resist such guidelines, even if I feel I have good reason for doing so? Is there a point where the guidelines become well established, and the simple act of failing to follow their recommendations will be considered care that isn’t evidence-based, which could trigger an investigation and disciplinary action from the Ontario College of Pharmacists? And recall that what I’m describing here—influencing practice culture and institutionalizing the resulting changes—was outlined by Tsuyuki in the Change Management chapter he co-authored.³

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While we have already looked at methods used by CPJ to influence the professional culture toward partisan ends—including growing the general partisan sentiment and defining what constitutes acceptable information—other tactics used to accomplish this present themselves through further reading of the journal. An important one that can be readily observed is the pressuring of individual pharmacists. The earliest obvious example I encountered in my reading was within the Sep/Oct 2018 editorial,²⁷ where the authors coin the term “full scope” pharmacy practice that later gets drilled into pharmacists over and over and over again.^17,28-36,xLi When introducing their term of choice, the authors explain that clinical services beyond the traditional dispensing role have previously been termed “expanded, advanced, or enhanced scope of practice activities,”³⁷ but that using such terms “suggest that these are luxuries or upgrades, that they are somehow optional … or exceptional.” Pushing against this idea, the authors point to the evidence to explain that these should be considered “essential services,” “[s]ervices that all patients should expect and be entitled to receive,” arriving at the term “full scope” to better describe them. My major criticism of such an idea resembles that which was described in a letter to the editor in the Jan/Feb 2019 CPJ,³⁸ where Brian Stowe, the author, outlined the concern that the suggestion that “all pharmacists’ expanded services should be considered ‘essential’ and all patients should be ‘entitled’ to receive them” presumes “that community pharmacists have unlimited capacity to provide all services to all people.” Stowe discusses the need to “prioritize the various service options available,” focusing on the importance for pharmacists to identify “their core value to patients” to help direct them. From his perspective, “the one role that distinguishes our profession from all other health care providers is our capacity to manage patients’ complex medication therapy issues.” In this way, Stowe accepts “that pharmacists providing services such as administering vaccines and prescribing for [urinary tract infections] may improve access and, potentially, provide cost savings,” but suggests that “the issues of access and cost savings are secondary to other values our profession provides patients,” and, rather, that “[w]ithout question, [his] core value lies in [his] capacity to manage patients’ complex medication therapy issues.”

The truth in this instance, however, may not be so simple, as outlined by the authors in their response to Stowe provided in the same issue.³⁹ Rather than attempting to pressure individual pharmacists to “provide all services to all people,” as I’m suggesting, the authors explain that their intent was to support the autonomy of individual pharmacists in order to empower them to “determine where our value most lies and act accordingly.” To do this, they were instead attempting to push for the provinces to remove “legislative limitations [that] prevent pharmacists from acting on identified needs even when it is deemed safe and effective to do so” and encouraging the creation of workplaces that “both supported pharmacists in providing these services and also refrained from imposing service counts that treat these activities as a commodity rather than a patient care activity.”^xLii I’d be inclined to take them at their word here, except that future articles better support my and Stowe’s interpretation of the editorial, and a good article to focus on in order to show this is the editorial in the May/Jun 2019 issue.³⁰ The article starts with a reminder of what “full scope” pharmacy practice entails, then presents the outside perspective that regulators are holding back the profession, going on to suggest that this viewpoint isn’t true—that it’s “merely yet another excuse put up by pharmacists.” Though the authors explain that “[t]he Colleges’ mandate is to protect the health of the public” and “[t]his role is different from advocacy for the profession of pharmacy,” they “believe that access to a full scope of pharmacy practice will significantly enhance the health of the public,” and they also “believe that it is the Colleges that have stimulated innovation in Canadian pharmacy practice.”^xLiii They suggest that “[m]odern regulatory philosophy” is driven by movements that “[foster] and [support] practice innovation that can not only protect, but enhance, public health,” and that disciplinary actions were rarely taken for clinical errors and never taken for innovations to practice. Therefore, “[i]t is clear that pharmacy regulators are not standing in the way of innovations in practice.” The authors then briefly outline potential barriers,^xLiv ultimately arriving at their belief that the issue is that individual pharmacists fail to adapt—that pharmacists will soon “run out of scapegoats and excuses,” and that “[m]ore often than not, we pharmacists are the ones standing in the way.” They then support this assertion with studies showing that “some pharmacists have a poorly developed sense of responsibility and lack confidence, find very elaborate and impressive strategies for not taking responsibility, blame corporations for holding us back, etc., etc.,” going on to point to a study that showed a lack of MedsChecks provided to patients over a four year period as proof that “many of us don’t practise to the scope of practice that we currently do have” and asking, “Should governments expand the scope of practice of a profession that doesn’t currently use the scope it actually has?”^xLv

With this, the authors promote a number of ideas I perceive as harmful, starting with the idea that the pharmacists are to blame because the service investigated is unquestionably valuable.^xLvi It similarly goes without question that performing everything within our “full scope” is valuable, that further expansion of our scope is valuable, and that we are additionally “holding back the profession” by not performing these valuable services because governments may slow this expansion if we aren’t making use of previous expansions of scope the way the authors feel we should. These are hyper-partisan ideas, pushing the importance of growth of the profession above all else, and they cause us to neglect discussions about the quality of our services, about reasons we should perhaps find the services themselves suspect.^xLvii It no longer becomes important to try and understand valid reasons why pharmacists would be resistant to a “full scope” of pharmacy practice because, once it’s taken for granted that such services or influential parties^xLviii within the professional environment can’t be at fault, it becomes easy to believe that it’s simply a matter of unconfident,³⁰ risk-averse,¹¹ evidence-illiterate¹⁷ pharmacists ignorantly resisting necessary change. This leads to a push for cynical, superficial, short-sighted, and potentially harmful “solutions” to the problem of “professional abstinence”—coined in an article in the May/Jun 2019 CPJ to mean “consciously choosing not to provide the full scope of patient care activities”³¹—including resorting to pressure tactics or manipulation techniques to “correct” undesirable pharmacist behaviours.^xLix

This leads us to the editorial in the May/Jun 2022 issue,³⁴ which showcases another dimension of the CPJ attempt to influence professional culture, but first a bit of background. CPhA announced the launch of their Pharmacy Workforce Wellness initiative in the Mar/Apr 2022 issue of CPJ,⁴⁰ which was intended to: (1) “collect accurate pharmacy workforce data;” (2) “promote research to help better understand the underlying causes of stress and burnout;” (3) “enable the development and dissemination of tools and resources;” and (4) “improve access to mental health care for our pharmacy personnel.” CPhA put out a national survey as part of this initiative, and the authors of the May/Jun 2022 editorial discuss some of its preliminary results, specifically that “[a]lmost all surveyed (92%) felt they were at risk of burnout, with half (51%) indicating that inadequate staffing is having a severe negative impact on their mental health.” They also pull from CPhA’s Expert Advisory Panel 2016 research report, which “revealed that 89% of respondents felt that there were too many competing priorities in the pharmacy workplace and stated that there was insufficient time for pharmacy staff to provide advanced services,” further showing that “69% of respondents felt that there [was] a lack of business models to implement advanced pharmacy services in the community pharmacy setting.” The authors then go on to excuse businesses for these failings, noting that: (1) Pharmacy is ultimately a business (that all businesses have projections or goals and so “[p]harmacists will always be asked by owners or operators to achieve certain prescription counts or clinical service targets”); (2) Formulas are used by corporate pharmacy chains to determine staffing levels (this number is largely based on total prescription counts, “[b]ut there is a supplementary formula used by some pharmacies for additional staffing related to clinical services, which is in addition to the standard staffing model for dispensing activities”); and (3) “[T]here is a real shortage of pharmacists.” After asking, “So, who’s right?” the authors acknowledge both that pharmacists had additional responsibilities during the pandemic and that it was a “stressful time for everyone”—even reminding us that “many have stated they were overwhelmed and understaffed for the additional tasks and activities”—but they add that “[i]t’s easy to point a finger at staffing shortages as the issue.” They express their surprise—eager surprise, it seems—to see that proprietary staffing formulas “account for paid clinical services,” though they briefly discuss whether they’re appropriate. Here, they suggest that there may be important things such formulas don’t take into account,^L but remind us that “these formulas are proprietary,” which means that businesses don’t share them with outsiders, and so they ultimately haven’t been evaluated by researchers. The authors also bring pharmacy regulators into the discussion, noting that “[t]he Institute for Safe Medication Practices Canada … has an entire document that lists environmental factors, workflow and staffing patterns that routinely lead to errors,” and yet “regulatory bodies regulate physical pharmacy space but not staffing,” merely stating “that staffing must be ‘adequate’ ” without providing further guidance.

Looking ahead, the authors assert that “[t]he ongoing shortage of pharmacists is not going to change in the foreseeable future,” and so they offer points to consider when determining how to “balance this divide of overwhelmed pharmacists and staff shortages”: (1) “[W]orkflow modernization” can lead to solutions; (2) There’s no excuse for staffing simply on the basis of prescription counts without considering clinical services in staffing formulas; (3) Pharmacy staffing and overall business practices are not robustly reviewed in undergraduate pharmacy programs, pharmacy management textbooks, or continuing education lessons; and (4) “There is an opportunity” to research existing staffing formulas and “define what adequate staffing entails.”^Li The authors then point to changing pharmacy workflow as a possible solution, outlining two ideas here, one being an uptake of pharmacy technicians practising “to their full scope,” rather than just relying on pharmacy assistants as support staff. (Here, I agree.) The other is to move the pharmacist to the intake counter so that they can “speak directly with the patient, have the opportunity to flag any clinical issues with the prescription, make any adaptations, conduct a medication review and identify the need for routine immunizations or screen for chronic diseases,” supporting this with the results of a poor study from the Nov/Dec 2021 issue of CPJ.^41,Lii (Here, I disagree.)

The most important concept I want to call attention to from this editorial is the way that the authors take what pharmacists are actually saying and bend it in order to shape the narrative in a partisan direction. Here, pharmacists complain that they’re suffering due to inadequate staffing, but the authors work to remove responsibility for this problem from businesses and redefine “properly staffed” to mean “using expanded scope metrics in their staffing models.” (And the authors confirm this in the Jul/Aug 2022 editorial, suggesting that “accessibility and patient care skills don’t mean much if pharmacies aren’t staffed adequately to provide this care,” which “means rethinking staffing formulas that are based on prescription volume only.”)³⁵ This shows what survey results and feedback from pharmacists mean to CPJ and CPhA. They aren’t useful for helping understand actual problems and leading to real solutions. They’re another tool to help persuade, to obscure issues inconvenient to stakeholders, and to help bias thinking, all at the service of growth of the profession and businesses.^Liii

*

It’s easy for me to imagine criticism coming my way after everything discussed above. It feels inevitable, not just because I’m human and presumably encountered flaws in my analysis, but because various groups and individuals benefitting from what I’m describing likely also benefit if I’m discredited. Don’t assume I’m implying that readers should disregard criticism directed at me (I’m sure that valid criticism exists), but it does mean that readers should carefully evaluate such criticism, especially if it comes from pharmacy owners or professional associations, for example.

One source of criticism that is likely valid is that my analysis harms unity within the profession,^Liv but how much that matters depends on what unity serves, as it currently exists. As I understand it, the strongest unified fronts in the current landscape appear directed toward various partisan agendas––all promoting growth above all else. Degradation of this type of unity likely weakens growth, and we should probably better evaluate our goals and the vision we have for the profession before we judge the actual harm. If we consider growth as our main goal, then certainly promoting an argument as I have can be considered at least potentially damaging, but I’ll gladly argue that growth shouldn’t be our primary concern, and that allowing other goals to supplant it—such as improving the health of our patients or our ability to effectively manage complex medication therapy issues^Lv—should be to the benefit of the profession.

And remember that what I’m describing more generally isn’t unique to pharmacy; many partisan pressures impact us in our day to day lives, and all are supported by similar strategies to some extent. What matters most for all of us is discovering our real principles, our core values, and not letting these sorts of partisan biases contaminate our thinking and push us down a different path.

*

This essay is the third in a series on partisanism. Next month, I’ll conclude with a further discussion of the importance of maintaining one’s freedom of thought and principles in the face of partisan pressure with a look at Homage to Catalonia by George Orwell⁴²—his account of his experience fighting on the Republican side during the Spanish Civil War.

Notes

i. CPhA is the national association that advocates on behalf of Canadian pharmacists for things like expanded scope of practice, suitable reimbursement for pharmacist services, and harmonization of pharmacist scope across the country. The association also produces tools and resources, including the Compendium of Pharmaceuticals and Specialties (CPS), which is probably the most commonly used source of information for medications and therapeutic topics for Canadian pharmacists.^43,44

ii. Examples of the former include the summary of the 2020 Canadian Cardiovascular Society’s atrial fibrillation guidelines in the Mar/Apr 2022 issue⁴⁵ and the practice tool in the May/Jun 2021 issue made to help pharmacists appropriately provide Mifegymiso, which is used for medical abortion, and manage its side effects.⁴⁶ With regard to the latter, the Nov/Dec 2018 issue contains a thoughtful article that approached the problem of leadership within the profession by describing how changes to the professional environment since WWII have added pressures to pharmacists while eroding their professional autonomy, using all this to suggest steps to empower pharmacists to help lead their profession to a better tomorrow.⁴⁷ A guest editorial in the Sep/Oct 2022 issue also impressed me, discussing the topic of professional identity formation—concerning “who we are in the context of our chosen profession”—arguing that, rather than attempting to shape students and pharmacists into uniform practitioners, those within the profession should embrace diverse identities—and work to support and assist these practitioners in navigating tensions and conflicts they come up against to help them uphold individual values—because it has the potential to help create a vibrant profession.⁴⁸

iii. I discussed this in greater detail in last month’s essay.² Refer to Note iii for most of the direct discussion.

iv. Partisan, in the sense that I described two months ago.⁴⁹ As a reminder, partisanism is always in the service of growth of the cause, with the profession and the business being two important partisan causes in the realm of pharmacy.

v. I should be explicit about my background before we get into it. I’m currently practising as a pharmacist in Ontario, where I have been doing so consistently since 2010. I also plan to delve into my work experiences over the course of this essay to better explain myself.

vi. I read issues published between 2018 and 2022. (There were gaps in my reading from 2018 to 2020, simply because I neglected to keep all the journals after I’d finished with them back then. I read 2021 and 2022 in their entirety.) Tsuyuki was appointed to this position in 2012.⁵⁰

vii. The authors explain that Kodak was successful for a long time, “a dominant player” in their industry for over a century. The company was first to develop and patent many aspects of digital camera technology but failed to effectively exploit such things while other companies did so, ultimately leading to the company declaring bankruptcy in 2012. In contrast, Hallmark, a company with a similarly long and successful history, adjusted their business model—expanding into the non-English-speaking market, utilizing the internet with e-cards, and allowing customers to record video greetings—thereby maintaining their position as a top privately held company and providing us an example of a “learning organization,” in other words a company “that purposively [takes] lessons from day-to-day experiences and [translates] them into new, and better, ways of achieving their vision.”⁴ I question how helpful these examples are, first because I suspect they provide a one-sided picture. In this way, is it possible that we can find examples of the opposite if we looked hard enough—of companies succeeding when they hold firm to working business models or of companies changing models that worked and bringing about failure? Secondly, how pertinent are such examples to pharmacy? When looking at the Kodak case, they failed to respond to disruptive technology (digital photography) that completely killed their existing business model (chemical-based film and paper). To suggest that the case is applicable to pharmacy would suggest that there is disruptive technology on the horizon that will render drug distribution obsolete. Unless such a thing can be demonstrated, Kodak’s failure teaches us little about pharmacy. One important and applicable lesson we can likely take away from Kodak’s failure, however, is one that went unmentioned in this chapter but was discussed in the Forbes article referenced: the importance of getting the best information possible to guide decisions and learning how to appropriately act on it.⁵¹ How this relates to pharmacy and what we can learn from pharmacy’s existing situation should become clear over the course of this essay.

viii. This is largely through reduction or prohibition of profession allowances, rebates from generic drug companies, and customer inducements (such as loyalty programs providing incentives for transferring your prescription).⁵²

ix. It’s probably worthwhile to distinguish between a pharmacy assistant and pharmacy technician. While both a pharmacy assistant and pharmacy technician are able to perform many important tasks within a pharmacy’s dispensing workflow—including order entry, counting and labelling medications, compounding products (though this has become much more limited, at least in Ontario, after recent changes to legislation), and customer service roles—a pharmacy technician is also able to perform additional roles that were previously only pharmacist responsibilities—including independently checking the technical aspects of prescriptions, taking verbal prescriptions from prescribers, educating patients on devices, performing point-of-care testing, and administering injections. Pharmacy technicians are regulated healthcare professionals who require additional training and certification whereas pharmacy assistants are largely trained on the job.^53,54

x. The Blueprint Task Force, composed of “broad representation from pharmacy stakeholders across Canada,” was established in 2007 “to define a vision and clear action plan for the future of pharmacy.” Later in the year, the Task Force launched its consultation process for the draft Blueprint, which included feedback from “over 30 national/provincial pharmacy organizations and corporate pharmacy head offices,” comments from “[o]ver 700 pharmacists, pharmacy technicians, and students in all practice settings,” followed by “six interprofessional focus groups, funded by Health Canada,” which were held across Canada early the following year. This process resulted in the finalized Blueprint document, “The Vision for Pharmacy,” which articulated this vision, a vision which effectively entailed: expanded scopes of practice for pharmacists and pharmacy technicians (transitioning pharmacists from a drug distribution role to a clinical role); improving safety and quality of care; improving collaboration between patients, caregivers, and various healthcare providers; engaging in practice research to inform policy and patient care; and paying pharmacists “in a manner that relates to expertise and complexity of care” (which I read as “more”). The document calls for “strategic action” in five areas to realize this vision: (1) pharmacy human resources; (2) education and continuing professional development; (3) information and communication technology; (4) financial viability and sustainability; and (5) legislation, regulation, and liability. A reasonably large part of the document breaks down each of these areas, describing them further and outlining “proposed key actions,” though many of these are still vague, idealized, and not necessarily helpful to provide concrete guidance. (As examples, “Ensure all pharmacy professionals, including students, value and develop life-long learning and personal performance assessment skills.” How does one go about this effectively? Does anyone actually have an answer to this? “Change culture to support new practice models.” How? Although we will get a sense of the CPJ answer to this second one as we continue.)⁵⁵

xi. I feel that I should also mention something about what comes off as a proposed representative nature of the Blueprint for Pharmacy, based on details provided about the consultation process. It’s possible that allowing individuals to comment and participate in focus groups provided insight to the Task Force to better adapt the eventual vision and strategy to match the views of these individuals, but it’s also possible that such feedback was instead used to better craft the rhetoric around the vision. In the case of the latter, stakeholders with greater involvement in the initiative—including the “national/provincial pharmacy organizations and corporate pharmacy head offices”—would be able to direct the initiative toward actions and ends they deem desirable while convincing individuals that they should similarly find them desirable. To better understand this manipulation tactic, refer to Politicians Don’t Pander by Lawrence Jacobs and Robert Shapiro⁵⁶ or my essay that discusses it in detail.⁵⁷

xii. This was an issue with the Blueprint for Pharmacy. The authors discuss the lack of detail about implementation activities provided when signatories of the Blueprint’s Commitment to Act declaration communicated online about the initiative. They also point to hospital pharmacy to show a lack of awareness among frontline pharmacists about similar initiatives, citing a survey about the Canadian Society of Hospital Pharmacists’ CSHP 2015 change initiative.⁷

xiii. Remember this, as we’ll see Tsuyuki later abandoning this idea.

xiv. Including the “development of payment schemes for clinical services and the regulation of pharmacy technicians.”⁸

xv. Once more, I highly recommend reading Politicians Don’t Pander to help understand how such things as I’m cynically describing are employed in the real world.^56,57

xvi. Mostly in-group, meaning pharmacists in this instance.

xvii. In Ontario, a pharmacist is able to renew a prescription for continuity of care, so long as the total quantity doesn’t exceed the lesser of either the total quantity of the original prescription or a 12 month supply. Adapting a prescription involves altering the dose, dosage form, regimen or route of administration of the original—although therapeutic substitutions are not allowed. For each intervention, the pharmacist must either be in possession of the original prescription or have access to the information contained in the original. They are then expected to assess the patient (ensuring they’re renewing or adapting safely and effectively), obtain informed consent (express or implied), write out a full prescription, inform the prescriber, and document all relevant information (such as the rationale for the decision to renew or adapt).⁵⁸ Examples that I witnessed where this was not done include workplaces where pharmacy assistants were informed by the pharmacist to automatically renew prescriptions for chronic medications for a set duration (i.e. one month) or situations where a dosage form is changed during an adaptation (i.e. changing a topical cream to an ointment) but most of this process was not followed—not assessing the patients, writing out a prescription, informing the prescriber, or documenting anything when doing so in either case.

xviii. Doesn’t the sarcasm seem not only unhelpful for this sort of discussion but also simply unprofessional?

xix. “So, yes, we are well trained to assess and manage pharmacotherapy, thank you.”¹¹

xx. While I’ve encountered knowledgeable pharmacists in my practice, I’ve also crossed paths with a number who struck me as downright ignorant. Similarly, while I’ve advised physicians about things that made me question their therapeutic knowledge, I’ve encountered many whose knowledge on both medications and therapeutics outshone mine. Perhaps the average pharmacist possesses “superior knowledge” of these topics as compared with the average physician, and perhaps there’s hard data to back this up. I doubt this, however, and I suspect that both professions are populated by a heterogeneous mix of practitioners possessing such a mix of knowledge, skills, beliefs, and experiences that it becomes difficult to even begin to compare such a thing.

xxi. One notable article is a commentary piece in the Jan/Feb 2019 CPJ that presents the lack of evidence for homeopathic medicines against the results of multiple surveys—the first indicating that 27% of pharmacist respondents would not pull homeopathy products from their shelves while, in the second, “19% of pharmacists agreed that ‘homeopathic medicines have well-established efficacy when used appropriately’ ”—to suggest that a substantial number of pharmacists “choose to make recommendations based on anecdote, testimonial and scientifically implausible theory,” and that this is unacceptable for our profession.⁵⁹ Perhaps even more notable in the context of this essay is the editorial in the Nov/Dec 2018 issue—not long after the Jul/Aug 2018 editorial we’re currently discussing, in fact—where Tsuyuki asserts that “many pharmacists, pharmacy organizations and policymakers are evidence-illiterate,” warning that pharmacists “promote things for which the evidence is weak or non-existent” (including homeopathy) when this is the case.¹⁷

xxii. Once again, refer to Note iii from last month’s essay to better understand my perspective here.²

xxiii. Aside from being firm, this is all what Tsuyuki failed to do here.

xxiv. And consider the statement that Tsuyuki leaves hanging by the end of this portrayal: that it makes “one wonder what the real motivations are for opposing pharmacists’ scope of practice.”¹¹ Is the implication that we are right to feel threatened?

xxv. What I’m describing is likely a largely indirect phenomenon involving a subconscious response to things not said directly, but Tsuyuki also employs overt statements to support this. Consider all the negative portrayals of physicians peppered across this editorial: physicians fail to provide patient care communications to pharmacists; physicians have inferior knowledge about drugs and therapeutics as compared to the pharmacist; physicians are hypocrites that accuse us of the conflict of interest of prescribing and dispensing when they fundamentally do similar things; physician care lacks evidence; and physicians circulate “repugnant and unprofessional” comments about us. And this all builds to a conclusion that we shouldn’t listen to physicians when working to define our scope of practice.

xxvi. I’m not alone in the essential points of my analysis here, and we can look to the Nov/Dec 2020 CPJ to see it. In this issue, three articles were published regarding independent pharmacist prescribing. The first was written by Eugene Yeung, a former pharmacist and current physician, arguing against pharmacist prescribing, detailing aspects of prescribing etiquette and responsibility between prescribers. Though the article contains sentiments that I find ignorant (such as assuming that independent pharmacist prescribing would be done irresponsibly and without collaborating with other healthcare providers) and inflammatory (including almost a threat that deciding to prescribe independently will relegate pharmacists to the realm of “alternative medicine practitioners”—alongside homeopaths, for example—and we will become abandoned by our patients in the process), it outlines what strike me as some valid concerns (questioning if pharmacists will effectively collaborate with others and worrying that pharmacists may practise beyond their knowledge or skills, potentially without pharmacists fully understanding this).⁶⁰

xxvii. The second article in the Nov/Dec 2020 CPJ discussing independent pharmacist prescribing is a response to the first,⁶⁰ written by a pair of pharmacists. Though it starts out promising (explaining that independent prescribing doesn’t cause pharmacists to stop collaborating with physicians, and touching on things like the experience with independent pharmacist prescribing in Alberta to help allay this concern), the authors spend a great deal of space picking apart specific points Yeung made when describing prescribing etiquette between physicians. (With this, they may be correct to suggest that his arguments are flawed, but they appear to imply that his assertions also have no merit. This strikes me as misleading, as the original letter contains what I see as some valid points stated poorly; while attacking these poor statements fails to answer these valid points, it gives an appearance that it does so.) From here, the authors begin to take umbrage at multiple “demeaning statements,” and go on to remind the readers that Yeung is ultimately a physician and not one of us, he doesn’t represent us (and, presumably, our interests), and that “[p]rescribing is a professional privilege granted by the public and they, not physicians, decide who gets to join the club.”⁶¹

xxviii. The third article in the Nov/Dec 2020 CPJ discussing independent pharmacist prescribing, written by Zubin Austin, is in reply to the first one,⁶⁰ but directed at pharmacists instead of its author. Austin expects the original article to elicit a wide array of conflicting emotions from pharmacist readers and explains the tendency to “circle the wagons and vigorously defend our interests, our profession and our aspirations for greater clinical significance” when criticism comes from outsiders. He then discusses the concept of “rolling with resistance,” citing motivational interviewing research to suggest that “[a]ttacking an individual or his ideas may simply drive that person deeper into a position, leading to a more defensive and confrontational stance that further reduces likelihood of a harmonious resolution,” and that “this tit-for-tat approach to changing minds and hearts rarely succeeds.” Austin discusses potential reasons this emotional response comes about (including the “historically fraught relationship between the professions of pharmacy and medicine around turf, role and dominance within the health care hierarchy”) and entreats pharmacists to attempt to read Yeung’s letter coolly and calmly. For, “[o]pposition to pharmacists’ prescribing is simply data, not emotion,” and “perhaps Yeung’s commentary has done our professional community a great service in actually articulating some of the nonverbal resistance we may experience on a daily basis from physician colleagues as our scope of practice expands” (here, he provides “Yeung’s question about ‘who is responsible’ ” as an example of a point that “is not completely unreasonable”). I feel that Austin’s advice given in conclusion does a lot to push against what I see as harmful tendencies promoted within both the other pharmacist response article and the Jul/Aug 2018 editorial,¹¹ and so it’s likely worth quoting at greater length here:

At the core of the commentary is something we can all agree upon—patient safety and quality health care. Although some of his language and word choices may appear inflammatory or insulting to some pharmacists, we can be magnanimous and believe that he, like all physicians, wants what all pharmacists want: the best possible care for our patients. Concerns about responsibility and orderliness may come across as thinly veiled excuses to deprive pharmacists of their professional evolution. But how are we explaining to patients (and physicians) what responsible pharmacist prescribing actually looks like? Stripping the emotion from our response, accepting his perspective and genuinely engaging in finding a solution is rolling with resistance, and it represents an opportunity to improve what we are doing. If we start our discussion simply assuming physicians are privilege-hoarders and noncollaborative, we are falling into an unpleasant emotional trap. If instead we critically self-reflect on why there is a perception of disorderliness to pharmacist prescribing—and set about doing something about this issue—then we are rolling with resistance and improving patient care.⁶²

xxix. To give readers a sense of the meaning of such a magnitude of effect, we can look to a 2003 meta-analysis in the British Medical Journal (BMJ) that looked at (among other things) the average reduction of blood pressure across several usual antihypertensive drug classes. It found that these average reductions were comparable across the drug classes, and the reductions shown (systolic/diastolic) were 7.1/4.4 mm Hg with half the standard doses of the agents, 9.1/5.5 mm Hg with standard doses, and 10.9/6.5 mm Hg with double the standard doses.⁶³ With this as a guide, the blood pressure reductions associated with pharmacist interventions reported in the Santschi article were in line with what should be expected with the addition of a lower dose of a medication for high blood pressure.¹⁵

xxx. To better understand how the Santschi article appears at an outset to have strong results but that its results become poor under closer scrutiny will require more direct discussion of statistical values. First is the confidence interval (CI), which is a measure of variation in the statistical estimate of the study’s result. It outlines the range of values we can expect the estimate to fall between if we repeat the test, or conduct a study in the same way, within a certain level of confidence.⁶⁴ (One helpful way to better describe the concept of “confidence” is to speak more specifically about this reproducibility. In this way, a 95% confidence interval means that we should expect that the result should fall within the interval 95 times when we perform an experiment the same way 100 times.⁶⁴ Though helpful, it should be noted that it’s likely an imperfect way of looking at confidence in the context of a meta-analysis, such as we’re describing. I should also make clear that a 95% CI is generally considered an acceptable level of confidence for such a study.) In the case of the Santschi article, the mean systolic blood pressure reduction was 7.6 mm Hg with 95% CI of 9.0 to 6.3, while the mean diastolic blood pressure reduction was 3.9 mm Hg with 95% CI of 5.1 to 2.8.¹⁵ This means that our estimated effect is the mean, but that we can be 95% confident that the “true” effect will land somewhere within the CI—that it could be as high as a reduction of 9/5.1 mm Hg or as low as 6.3/2.8 mm Hg, but it’s more likely to be somewhere in the middle, closer to the mean. Seeing these results alone suggests that we can have high confidence in the positive effects of pharmacist interventions in this case. However, this relies on using a fixed effects model, assuming that all of the studies being examined as a whole are considered to have been conducted under similar conditions with similar subjects, meaning the only difference between studies is their power to detect the outcome of interest.⁶⁵ If there are too many differences between studies, we lack the ability to effectively compare across them, which harms our ability to generalize the results that we get after this comparison. How significantly this affects a meta-analysis can be calculated with a number of values, two of which were reported in this study. The first is I², which describes the percentage of total variation across studies that is due to heterogeneity rather than chance. Within the 2003 BMJ article that describes the development of this measure, the authors explain that the range of I² values that can be calculated range from 0% to 100%, where “[a] value of 0% indicates no observed heterogeneity, and larger values show increasing heterogeneity.” Though specific categorizations of values for I² are not said to be appropriate in all circumstances, the authors “tentatively assign adjectives of low, moderate, and high to I² values of 25%, 50%, and 75%.”⁶⁶ With this in mind, the I² values for systolic and diastolic reductions reported in the Santschi study were 67% and 83%, respectively,¹⁵ meaning that “most of the variability across studies was due to heterogeneity rather than chance” (here I’m quoting what the authors of the BMJ article had to say about examples given with calculated values above 60%). The second value, the prediction interval (PI), presents the expected range of true effects in similar studies. When there’s a lack of heterogeneity between studies analyzed, the PI will be close to the CI, whereas it will be larger as heterogeneity increases. Within a 2016 BMJ Open article, the case is made that the PI can be used to make more informative inferences from meta-analyses, including allowing us to see when there are “settings where conclusions based on CIs will not hold.”⁶⁷ The 95% PIs reported in the Santschi study were reductions of 13.9 to 1.4 mm Hg for systolic blood pressure and from a reduction of 9.9 to an increase of 2.0 mm Hg for diastolic blood pressure.¹⁵ This suggests that, while there may be cases where a pharmacist intervention can achieve a better effect than expected from the mean and CI reported, we can no longer be confident that our intervention will do much for the patient—and there may even be pharmacist interventions that are harmful.

xxxi. In their discussion, the authors cite a 2013 Health Policy systematic review that “reported mixed or inconclusive evidence in support of expanding the role of community pharmacist in healthcare delivery,” explaining that the article “focused specifically on community pharmacists” rather than investigating studies involving interventions by both community and clinical pharmacists, as was the case in their study.^15,68

xxxii. All pharmacists in the enhanced pharmacist care arm were paid $150 for the initial visit, followed by $75 for any additional visits. Pharmacists in this arm were further randomized to a “Fee for Visit” and a “Pay for Performance” arm, where the latter was additionally paid bonuses for reaching clinical targets ($125 per patient meeting 50% of the recommended blood pressure goal and $250 per patient reaching target blood pressure). This was for the purposes of a substudy, the results of which were not reported within this one.¹³

xxxiii. The study took place in Alberta, where pharmacists can independently prescribe, and allowed the “prescribing/titrating of drug therapy if deemed necessary,” within the enhanced care arm.¹³ Is the blood pressure reduction we should expect impacted if this is carried out in another jurisdiction where pharmacists can’t independently prescribe? What about prescribing without the same time, resources, or supports involved? How strongly do the fees provided to pharmacists impact their interventions (would the same care be expected with the Ontario MedsCheck funding model, given $60 annually and $25 per follow up rather than $150 initially and $75 per follow up as provided in the study)? As well, what happens beyond six months? Is the benefit maintained? Does the reduction in the usual care arm “catch up” at some point?

xxxiv. Should we take the aforementioned BMJ article as a benchmark for expected blood pressure reductions, however, it’s plausible that, after we spend all that time and resources on intensive pharmacist interventions, we achieve less than we would if the patient took a low dose of an antihypertensive medication instead.⁶³

xxxv. And with Tsuyuki as a co-author.¹³

xxxvi. The authors explain that both terms involve the spread of false information, with the distinction that misinformation concerns this spread, but “without malicious intent,” whereas disinformation concerns knowingly spreading false information in order to “intentionally mislead or manipulate the narrative.”¹⁸

xxxvii. Hopefully the case against this assumption is beginning to take shape.

xxxviii. Though Tsuyuki was not a co-author, frequent readers of CPJ will notice familiar names here.²⁰

xxxix. They describe: (1) “[A] Utah pharmacist who fraudulently filled out COVID-19 proof-of-vaccination documents [who] was fined and resigned their license to practice;” (2) “Another Utah pharmacist illegally imported 550 kg of hydroxychloroquine and chloroquine through a non-FDA-approved manufacturer” and ended up “sentenced by the courts and is currently under probation with the regulatory body, with conditions on their license;” (3) “A New Zealand pharmacist [who] unknowingly distributed a COVID-19 disinformation magazine after allowing the magazine to be left on the pharmacy counter along with other pamphlets,” ultimately “receiving a warning from the regulator;” (4) “An Ontario pediatrician [who] was disciplined for tweets claiming that lockdowns and vaccines were unneeded,” who then “received a caution from the regulator;” (5) “An Ontario family physician who has been spreading disinformation on social media” ended up being “banned from administering the COVID-19 vaccine, prescribing ivermectin and other medications not approved for COVID-19 and providing exemptions for COVID-19 testing, face masks or vaccination,” and “is being further investigated for ‘making misleading, incorrect or inflammatory statements about vaccinations, treatments and public health measures for COVID-19’ and for being ‘incompetent in relation to his communications;’ ” and (6) “A physician from British Columbia who stated that vaccines are dangerous and that COVID-19 is not worse than the flu” who was “reprimanded and banned from speaking about COVID-19.” With regard to the Ontario physicians, both “continue to influence their 46,000 and 124,000 Twitter followers, respectively,” and the second is said to be “unapologetic.” With regard to the BC physician, “he is in a legal battle with the regulatory body regarding his right to free speech.”²⁰

xL. I discussed this in detail in a previous essay.⁶⁹ In summary: (1) The assertions supporting the main recommendation are not evidence-based; (2) The authors provide a misleading portrayal of the available data to suggest greater patient needs and expected benefits than can be demonstrated; (3) The guidelines are funded by the makers of Narcan (naloxone), who stand to profit enormously from such recommendations; (4) The cost is largely hidden from unsuspecting patients who don’t have to pay for naloxone in a number of Canadian jurisdictions, including in the most populous province; and (5) Promoting potentially wasteful practice can divert healthcare funds from other needed, evidence-based programs and services (including a naloxone program targeting only high-risk patients).

xLi. Two points here are worth mentioning. Firstly, recall from last month’s essay that “endless repetition and oversimplification” is employed to control minds.² Secondly, I’ve encountered the term, “full scope,” used in various professional settings and within pharmacist social media groups without requiring any further clarification, meaning the term has taken root within the target group.

xLii. Remember this final point later.

xLiii. To demonstrate this, they explain that “it was the Alberta College of Pharmacists that spearheaded the effort to get pharmacists prescribing in Alberta” and that “[t]he BC College of Pharmacists drove the establishment of PharmaNet, and the requirement for pharmacists to review all drugs before dispensing any prescription, and now, have applied to the Minister of Health for authorization to prescribe.”³⁰

xLiv. “If the Colleges are not holding us back, then who is? Is it government? Certainly, when a new service requires a change in legislation, then, yes, that is a barrier. But not an insurmountable one. Is it our culture? Is it the pharmacy corporations? Is it our ambivalence?”³⁰

xLv. One aspect to this idea that I find it necessary to comment on is that we can agree on the data and widely disagree on the conclusions that explain it, and it’s important to more specifically discuss the MedsCheck data cited along with the authors’ presumptions about how we can explain such data to better make sense of this concept. (For readers unfamiliar with the MedsCheck, refer to Note iii from last month’s essay, where I summarized information from the Ministry of Health and Long-Term Care’s website.)^2,70 The data cited in the editorial come from a study by MacCallum et al., which found that,

[w]hile approximately half of the patients with diabetes received a MedsCheck review, 2/3 only received one annual review over the study period of 4 years (despite being eligible for yearly full reviews, paid for by government payors), and 97% never received any follow-up visits over 4 years (despite being eligible for up to 4 paid follow-ups per year).^30,71

The editorial authors have nothing more to say about this beyond what was mentioned already in the body, namely that this is proof that “many of us don’t practise to the scope of practice that we currently do have.” Taking this together with other comments made in the article leaves us with the unspoken conclusions that pharmacists are simply choosing not to update their practices in a useful way and that they are refusing to take responsibility for this poor decision. But this isn’t the only explanation for such data. One alternative answer came from the secondary, guest editorial written by Derek Jorgenson in the Jul/Aug 2018 CPJ. Citing the same data, Jorgenson suggests that this evidence supports the argument that pharmacists are struggling at helping patients within their care because we lack “a formal system of specialist pharmacists to refer complex patients” and have been “forced to try to do everything on our own.”⁷² Or there’s my explanation that community pharmacists commonly feel a general sense of unease around predatory practices where pharmacists try to extract more money from an unsuspecting public, and so they are resistant to engaging in lower quality services that business pressure compels them to perform. My explanation has the benefit of explaining the major discrepancy noted between annual and follow-up services performed, because it’s easy for businesses to track the eligibility of annual services and attach metrics to them simply because a patient qualifies if it’s been at least a year since the service was last billed. In the case of follow-up MedsChecks, however, patient eligibility is a matter of precise, clinical circumstances and pharmacist discretion, which makes these services much more difficult for businesses to track and enforce. If there’s truth to this perspective, this data may even demonstrate actual professional autonomy asserted by employee pharmacists in their attempted refusal to perform the services—though a sad and severely limited autonomy, I should add.

xLvi. Contrast this thought against data regarding a similar service in a different jurisdiction. A study by Necyk et al. in the Sep/Oct 2021 CPJ explored patients’ perception of the care they received through the Comprehensive Annual Care Plan (CACP) program, which is funded by the government of Alberta. The study found that “most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls.” Interestingly, the authors also found that less than 50% of patients for whom the service was billed were even aware that it was performed.⁷³ (As a side note, even though Tsuyuki was a co-author for this study, I can’t recall him ever bringing it up when discussing the evidence for pharmacist care.)

xLvii. Much of the content of this editorial echoes what was expressed during my last professional assessment with the Ontario College of Pharmacists (OCP). I was told by the assessor that I should be billing the government for anything and everything I do within the pharmacy without worrying about the validity of the claim—that I should bill for any and all recommendations sent to prescribers, even if it is clearly outlined as not a billable service in the Pharmaceutical Opinion program,^74,75 and that a MedsCheck should be billed without concerning myself that I did enough to constitute the full, billable service. (I believe the justification for this was that pharmacists are getting too hung up on getting in trouble for billing Pharmaceutical Opinions and MedsChecks, and that allaying these concerns will bump up the numbers. This was in support of the exact same argument employed by the editorial authors, that the government won’t continue to expand pharmacists’ scope if we aren’t using the entire scope that we already have.) Not once during the assessment did we talk about the ethical considerations behind the billings or the value of these services. Because the assessor agreed with the authors’ partisan strategy, we can make sense of the assertion at the end of the editorial that “[i]t certainly isn’t the Colleges that are standing in the way” of the profession³⁰—though I’ll still argue that pushing for quantity in this fashion empowers practitioners to perform poor quality, low impact, and incomplete services, which could be interpreted as a different way of holding the profession back. I find it necessary to add that these same sentiments—those outlined by the CPJ authors and the OCP assessor—were also expressed by my aforementioned “mentors,” who stood to profit from a push to bill more of these services.²

xLviii. Notably, the signatories to the Blueprint for Pharmacy’s Commitment to Act pledge include numerous national pharmacy organizations, provincial pharmacy associations, faculties of pharmacy, provincial regulators, and major pharmacy chains.⁵⁵ Committing “[t]o move the profession forward” and to “refer to the Blueprint when developing [their] own strategic plans” likely keeps the signatories in the good graces of the editors and authors published in the official journal of the national association that organized and developed the Blueprint plan and coalition,^1,6 even if the vast majority of signatories failed to outline how they were doing so.⁷ And I suspect we’ll find similar names in the lists of supporters, affiliates, and sponsors for more recent CPhA initiatives, such as Canadian Pharmacists Scope (CPS) 20/20⁷⁶ or Pharmacy Workforce Wellness.⁴⁰ (I only refer to a vague suspicion here because it was much harder for me to find such information for these specific initiatives. For CPS 20/20, the closest I came across was a list of “Organizational Members”—mainly provincial associations—and “Organizational Affiliates”—composed of a larger list of mostly drug companies, but also pharmacy chains and at least one insurance provider and financial institution—within CPhA’s Q2 2018 Stakeholder Update document.⁷⁷ Though CPS 20/20 is mentioned in this document, the document itself concerns CPhA’s overall activity through this period—with a focus on the Canadian Pharmacists Conference 2018, for instance—and so members and affiliates listed were not necessarily involved in the initiative, but those that were involved are likely represented in these lists to some extent. As for Pharmacy Workforce Wellness, the page on the CPhA website outlining the initiative details a short list of sponsors—all major pharmacy chains and drug companies—but it likely only gives us a severely limited idea of all the influential parties involved.)⁷⁸

xLix. An example of the former includes a commentary article in the Sep/Oct 2020 CPJ, where there is a proposal for the creation of a “registry of abstinence issues.” For this, pharmacy students are asked to engage in the surveillance of their preceptors and other pharmacists in order to report any examples they witnessed of “unacceptable” practice.³² An example of the latter includes a commentary article in the Mar/Apr 2022 CPJ that proposes gamification as a method for influencing pharmacists to engage in “desired professional behaviour.”⁷⁹

L. “It’s important to recognize that neither of these formulas takes into account the volume of [over-the-counter medication] questions, phone inquiries or collaborative activities with other health care professionals,” for example.³⁴

Li. And the authors appear to be jumping at this opportunity.

Lii. The cited study was a retrospective chart review (looking over a 6 year period) of patients who received a CACP in two community pharmacies that use the “Pharmacist First” workflow model, reviewing reductions of blood pressure and hemoglobin A1C (which is a measure of control of diabetes over the previous 3 months). It found a significant reduction of blood pressure from baseline (8.6/3.4 mm Hg systolic/diastolic), but not A1C, which would be meaningful results if these pharmacies were compared against others with more typical workflow models. As is, it doesn’t tell us if these results are better or worse than what should be expected if the pharmacist remains away from the intake counter.⁴¹ And, from my experience, the last thing a pharmacist needs in order to allow for the better provision of expanded scope activities is to be the first point of contact—with the exception of extremely slow-paced work environments, which seemed to support this kind of model when I worked in such places. Better, from my perspective, would be to have well-trained support staff who know when to appropriately triage patients to the pharmacist.

Liii. Again, Politicians Don’t Pander is an excellent source that explains this in greater detail.^56,57

Liv. And the importance of unity is another point that’s regularly repeated by CPJ^36,40,80-82—another case of “endless repetition and oversimplification.”

Lv. Despite what is commonly suggested, including within much of what I read for this essay, these things are not synonymous with growth of the profession or our businesses, and this growth will not achieve these separate goals unless we direct it toward them.

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