An appeal for scientific criticism in pharmacy practice

A much revered wise-saying in Akan goes like this; “Dua kontonkyitonkyi na ɛma yɛhunu dwumfoɔ”. An English rendition of which will be, “a crooked piece of wood reveals the skillful carver”. This adage gives us a test for artful craftsmanship, pointing to the fact that it takes so much learned or innate skill to make meaning out of a seemingly useless situation. In the context of professional practices it illumines us to understand that skill is what sets apart the professional from a lay person.

In our modern world, many thanks to information communication technology(IT), both pharmacists and the lay public now have an almost free access to a large breadth of information on drugs, specifically, and healthcare in general. But much as breadth in perspective is seen effortlessly, so much skill and labour are required to discover depth. The capacity to process and make meaning of the same information presented to both the pharmacist and the lay person is what sets the one apart from the other. And this skill is most relevant in situations when there are obvious contradictions or unfilled gaps with the pieces of information presented. It is requisite for a pharmacist, a sine qua non, in order for him or her to excel in the chosen profession, to possess the skill to expertly sift the available pieces of information on drugs and take an informed position. There will be no difference if a pharmacist also absorbs any information presented hook, line and sinker just as the lay person. In the events when there are unfilled gaps with the available information, a recourse to an educated guess will be necessary. A pharmacist who proceeds along this line of thought is guided by the merits of scientific criticism in his or her practice.

A recent report tells of a pharmacist who declined to dispense diazepam to a client, having been requested of the latter for that drug by name to relieve an episode of insomnia, and recommended the intake of chamomile tea instead. Was scientific criticism involved in the decision-making process here? That depends on what this pharmacist would give for a reason. It is a scientific argument if the pharmacist’s reason is that diazepam is a controlled substance, a prescription-only drug (POM), and therefore the client required a valid prescription to access it (The Legal Argument). It is a scientific argument if the pharmacist is just being mindful that the habit of taking a drug to induce sleep could lead that client to a state of drug dependency or addiction (The Addiction Argument). It is again a scientific argument if the pharmacist’s recommendation was a matter of preference for natural therapies and a personal disposition to promote any therapy of natural origin above synthetic drugs (The Orientation Argument).

In this case, however, an argument made within pharmacology (The Pharmacology Argument) will not stand the test of scientific criticism. Why, because whereas a large body of knowledge has been documented in literature in favour of diazepam, currently there is an information gap as far as the herb chamomile is concerned. The pharmacist most likely knows, or at least can easily access, so much information on the pharmacology of diazepam, including its chemical identity, mechanism of action, duration of activity, known and predictable drug interactions, risk of tolerance and its addiction potential, safe dosing regimens, and much more. This wealth of information on diazepam has, rather unexpectedly, bred a common phobia against it within the healthcare community. On the other hand, the literature is currently not as much rich with these pieces of information towards chamomile. It is fine if this dearth of information on the pharmacology and toxicology of chamomile is appreciated and not misinterpreted to mean a better safety profile of this herb compared to diazepam. To wit, our pharmacist will not be right in this instance if his or her recommendation to that client was on the basis of an idea that chamomile tea is a safer option.

To elaborate on the pharmacology argument, how else could chamomile effect sedative properties if it does not contain active principles (secondary metabolites) which also interfere with the activities of one or more neurotransmitters in the CNS? Assuming even that the active principle(s) in chamomile does not exert action on the GABA-ergic neuronal pathways diazepam is known to be involved with, it is very reasonable to say that that active compound and diazepam are both molecular entities and for that matter the classical laws of drug-receptor interaction hold all the same. The only difference here being that whereas the active principle(s) in chamomile is naturally derived, and perhaps not yet isolated, diazepam is a purely synthetic drug. It is only when we were to have a detailed pharmacological profile of chamomile can we scientifically compare this natural therapy with diazepam along the lines of pharmacology.

It makes so much difference how we defend our positions and choices in the practice of pharmacy. If doing a scientific criticism means taking a position opposed to the orthodox viewpoint on the matter do it for being the noblest course of action. This holds true so long as some pieces of evidence, either documented or experiential, can be adduced in defence of the position espoused.

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.