Decision making in clinical practice

In one hospital setting a doctor calls the Pharmacy Unit on the phone, and when the pharmacist’s assistant picks up he furiously passes on this message: “Tell your pharmacist never to change my prescriptions, okay”. The pharmacist upon taking delivery of this display of overt interprofessional animosity decided to query the disturbed doctor. The case in reference was a known hypertensive patient who presented with upper respiratory tract infection (URTI) on the previous visit, for whom this doctor had prescribed a full-dose regimen of an ephedrine-containing cough mixture to be taken at home over a period of seven(7) days. The pharmacist apparently got alarmed to the adrenergic effects of ephedrine and the possibility for the said formulation further raising this patient’s blood pressure(BP) and his intervention was substitution with a generic formulation having both expectorant and antitussive effects. In this hospital the pharmacy staff are deprived of patients’ medical folders at the point of service delivery, so that this pharmacist did not have information on the patient’s BP as well as the presenting symptoms at the time and so his action was based on pure theoretical judgment.

In the dialogue that ensued between the pharmacist and doctor the former explained the theoretical reasoning behind his action, whilst the latter on his part intimated that the former should have conferred with him on that point prior to any such action. And the doctor quickly added a remark to the effect that, in all cases, the final authority for therapeutic decision-making resides with a doctor and that a pharmacist is duty-bound to dispense any prescription regardless of his/her opinion on it. The pharmacist could simply not accept this assertion, of course not in this era of the clinical pharmacy movement when the hospital pharmacist is fervently seeking to establish the concept that therapeutic decision-making is not the prerogative of the medical profession, but a shared responsibility among the healthcare team.

The twist which occurred on the doctor’s side of the dialogue is the most fascinating. Admittedly, the pharmacist committed an ethical error in not consulting with the doctor on his opinion on the choice of cough mixture and about his intended action prior to it, by which means he could have effected a perpetual positive change in the doctor’s practice in first pass. Notwithstanding, for the doctor to appropriate to himself alone the final authority for therapeutic decision-making is a fallacy which requires remediation. The prevailing idea within the medical profession that a doctor’s thoughts are superior to those of all other healthcare professionals is yet another consequence of the rather outmoded concept of the healthcare team, the hierarchy model, wherein the doctor is placed at the top of therapeutic decision-making. It is against some of these fallacies and old-fashion models that pharmacists today should deal with if the clinical pharmacy movement will make further inroads.