Can Pharmacists Solve the Family Doctor Shortage?
As wait lists for family physicians in Canada get longer, pharmacists across the country are filling in the gaps. In recent years, five provinces—British Columbia, Saskatchewan, Nova Scotia, Newfoundland and Labrador and Ontario—have expanded the list of ailments pharmacists can treat. Not everyone thinks this is a good idea: the Ontario Medical Association has argued that pharmacists lack the medical training needed to safely diagnose and treat complex conditions. Other groups like Doctors of B.C. have said legislation would be better served supporting the foundation of Canada’s primary care system: doctors.
For Kara O’Keefe, a second-generation pharmacist from rural Newfoundland and a Canadian Pharmacists Association board member, the expansion of pharmacist powers has been a game-changer. Here, she explains why the shift can help patients, reduce burnout and make the health-care system more efficient.
Why are we seeing more expansions of pharmacist powers? Are doctor shortages playing a role?
The lack of access to primary care is certainly something that’s on people’s minds. All kinds of health professions are having issues with recruitment and retention: family physicians, nurses, pharmacists. Governments are looking for ways to optimize people’s care, so that means using the health-care professionals we do have at a time when caring for patients is much more complicated than it used to be. We have higher rates of chronic disease because patients are living longer. Both of my parents are baby boomers, and I can see the dollar signs going up when it comes to their care. Gone are the days when we can expect one doctor to manage a patient’s care on their own. Expanding the scope of pharmacists’ work reduces the pressure on doctors while making things more efficient for patients.
Most provinces let pharmacists treat certain ailments even before the pandemic. How did COVID-19 change the game?
In the early days of COVID-19, Health Canada put exemptions in place so pharmacists could extend opioid prescriptions. This was helpful because many patients lacked access to their primary care providers during that time. The person that they could access throughout was their pharmacist. That shift allowed us to sharpen our prescribing skills.
Which ailments can pharmacists now treat?
It’s different for each province, but we’ve seen some common ones popping up across Canada. This includes uncomplicated urinary tract infections, or UTIs, that don’t require urinalysis. There’s also strep throat or pink eye. We can treat bacterial or viral infections of the eye, allergic reactions of the eye—a lot of the things usually treated with over-the-counter medications.
How do the rules differ from province to province?
Starting in June of 2023, B.C. pharmacists got the right to prescribe medications to treat 21 common ailments, such as allergies, shingles, cold sores, pink eye and uncomplicated UTIs. That same year, Ontario granted its pharmacists the ability to treat 19 minor ailments, including hemorrhoids and mild acne, two ailments that pharmacists in every province can now treat. Now, the Ontario government is considering further expanding the list to include ailments like sore throat, calluses and corns, mild headaches, shingles, minor sleep disorders, fungal nail infections, swimmers’ ear, head lice, nasal congestion, dandruff, ringworm, jock itch, warts and dry eye.
Alberta has something called “advanced practice prescribing.” How does that work?
It’s been around since 2007. There’s no limit set on how a pharmacist can manage a disease—it is left to the pharmacist’s discretion as to what is and isn’t appropriate for them to treat. So for example, if a patient came in with asthma and the pharmacist believed their inhaler needed to be changed, they could prescribe independently as long as they feel that they have all the information to do that safely. Alberta is the only province where we don’t put those parameters on a pharmacist, just as we don’t put parameters on the ailments that a physician or a nurse practitioner can treat. We trust them to know their area of expertise and their role in that patient’s care
Your home province of Newfoundland and Labrador recently expanded the scope of practice for pharmacists. What’s the situation there?
Last April, pharmacists here were granted the ability to assess and prescribe for pink eye, fungal nail infections, shingles and UTIs, for a total of 33 common ailments. We’re now also able to extend prescriptions to a maximum of 12 months, rather than the previous 90 days.
What does this look like on the ground?
For example, this past summer, while working in Bell Island’s small cottage hospital off the coast of Newfoundland, I had a patient ask about buying an over-the-counter cream for a rash. After assessing, the rash turned out to be shingles, which can spread and cause long-term nerve pain if it’s not treated properly. The faster we remedy it, the better. On that particular day, our emergency room was closed, so if I hadn’t been able to assess and prescribe for her, she would either have gone a full 24 hours without care or been brought by ambulance to the emergency room in St John’s. This was an assessment that a pharmacist could do for $20. These new expansions of pharmacist duties can both improve patient care and relieve some of the financial stress on our health-care system. In Newfoundland alone, we’ve had almost 15,000 patients use services like this. That’s 15,000 assessments that avoided an emergency room visit or a physician visit—and done for less money.
Are there ailments you and your patients wish you could treat that you can’t?
On Bell Island, we have high rates of diabetes. But if someone needs an adjustment, I cannot make changes to their medications when I’m monitoring their blood sugars. Luckily, I have a strong relationship with our nurse practitioner. But on a regular basis, I hear patients say, “Why can’t you just do this yourself?” It can be frustrating for patients, because at the end of the day, their pharmacist is doing the assessment and they’re making recommendations, but they’re still having to bounce those off to a physician or a nurse practitioner.
What’s the economic argument for the new pharmacist rules?
I would argue that, as a taxpayer, if I’m going to subsidize the education of my pharmacist, then I want them to be doing a lot more for me than blindly filling a prescription. Pharmacy students learn how to differentiate whether somebody has a fungal skin infection or dermatitis, something that’s now backed up by provincial legislation. These are things pharmacy students are more than comfortable doing. It’s not just us: nurse practitioners, physiotherapists, paramedics are all being trained more heavily. In order to figure out this crisis, we have to get everybody playing on the same field, and everyone needs to be playing at the top of their game.
Recently the Canadian Foundation for Pharmacy found that 80 per cent of pharmacists in Canada are at risk of burnout and only about 40 per cent are fulfilled by their work. Do you worry that increased responsibilities for pharmacists will lead to more burnout and dissatisfaction?
I would argue that it’s much more frustrating to know you are capable of helping a patient but not able to do so. If I have a patient—and I know exactly what to do, how to manage them, what lab work needs to be done—but I need to tell them to go sit in an emergency room for 10 hours for that to happen, that stresses me out. My father is also a pharmacist; he will tell you he’s more fulfilled in his job now than he has ever been. He can help his patients and make a difference because not everyone needs to be sent to a physician or visit the emergency room. A lot of patients simply aren’t going to go to the ER, especially if they are frail or elderly. If they do go, they might contract infections or fall.
Some physician groups like the Ontario Medical Association say pharmacists lack the medical training needed to safely diagnose and treat complex conditions. Is there any validity to those concerns?
The majority of physicians who I speak with on a daily basis do not feel this way, and I don’t hear those sentiments in the community. If the physicians who have these opinions read the Canadian Pharmacists Journal, they might change their minds: we have great evidence in the form of randomized control trials that pharmacists can treat ailments like UTIs or strep safely and effectively, and that patients are satisfied with their treatment. This has been happening in Alberta for almost 20 years. There have been only very minimal complaints put into the College of Pharmacy about pharmacists acting inappropriately, but at a rate no higher than nurse practitioners or physicians. We also haven’t seen the rate of liability insurance go up significantly for pharmacists. If we were seeing more liability claims, our insurance premiums would go up, and that has not occurred.
Are you concerned about fragmentation of care?
It is the government’s responsibility to catch up to that, not pharmacists’. It especially needs to create digital solutions. In Newfoundland, we’re further along than in Ontario when it comes to electronic health records. If I fill in a prescription for somebody’s birth control, then it goes into their file, which is attached to their personal health number, which also contains records of their blood work and imaging. Emergency room nurses or physicians have access to these. It’s the responsibility of all health-care providers to contribute to patients’ files. It shouldn’t be left to one group to carry the burden of that.
What about the opposite? Do you fear an unnecessary overlap in care?
We’re not looking to replace physicians or nurse practitioners. But there’s always going to be overlap in our jobs. That’s the nature of things. We have to focus on using all of our resources to the best of our capacity and getting patients what they need. That’s what it’s about at the end of the day: the patient is in the centre, and we all work for the patient.
This interview has been edited for length and clarity.
