Pharmacists take on more active role in patient care

Bill would allow input in treatment decisions

By Eric Goldscheider

AMHERST - After Denis Cunniffe dons his white cotton pharmacist's jacket at 8 a.m., he can expect to spend the next 12 hours filling around 250 prescriptions for CVS customers.

There is a certain mechanical drudgery to the job, and Cunniffe can't afford to make a single mistake. So the nuts and bolts of putting the right pill in the right bottle at the right dosage requires his complete concentration. Cunniffe talks of getting into "a zone where you clear out any distraction around you."

But "the best part about the job is the people," he said. "I'm easily accessible. You don't have to make an appointment, and there's no fee to say hello to me and ask me a question."

Pharmacists such as Cunniffe are taking an increasingly active role in the management of a patient's illness. These professionals now often informally monitor the effects of a drug on a patient, confer with doctors on dosages, report signs of potentially unsafe drug interactions, or suggest cheaper or more effective alternatives.

Soon such collaborations could be formalized in Massachusetts, one of the few states that has yet to develop provisions for what is called collaborative drug therapy management. Legislation introduced this year by state Representative Peter J. Koutoujian of Waltham would allow pharmacists in Massachusetts to participate in the "initiating, monitoring, modifying, and discontinuing of a patient's drug therapy" based on a standing written agreement between the pharmacist and a physician.

Supporters of the legislation, such as Professor Joy Evans of the Massachusetts College of Pharmacy and Health Sciences, argue it would save lives and money by reducing the estimated 200,000 deaths, and more than $121 billion in hospital admissions that occur nationally each year from adverse drug reactions and treatment failures.

Evans herself practices this approach by managing diabetes treatments for patients she sees as a pharmacist at the South End Community Health Center in Boston.

"I look at their symptoms and lab data and help to manage disease states," said Evans, adding that educating patients about their medications is becoming a bigger part of the pharmacist's job.

The American Pharmacists Association in Washington, D.C., acknowledged that the added responsibilities for pharmacists under the collaborative program could add to patient costs in the short run. But, insurers have been willing to bear these costs because of the anticipated savings, said an association spokeswoman, Susan Winkler.

Insurers would "rather pay for the flu shot than pay for the flu," she said. "There is a recognition drugs work if you take them correctly and they cause great harm if you don't. The pharmacist's job isn't done when the patient leaves the pharmacy."

But doctors in Massachusetts oppose the collaborative drug therapy legislation. "It does not address ethical issues involved in allowing pharmacists who dispense and sell medications to actually choose the medication that is most appropriate," said Alan M. Harvey, president of the Massachusetts Medical Society, in a statement about the proposal when it came up for a hearing in September. "The conflict of interest in such broad authority is readily apparent." But pharmacists said their constant interaction with customers, from ordinary chitchat to deeper discussions about their health, often put them in the position to spot trouble.

One scenario Cunniffe said he often encounters concerns the high blood pressure medication Zestril. A patient will sometimes "develop a cough that won't go away," he said, which is a "classic side effect." Under the proposal, he might be able to dispense an alternative medication without sending the patient back to the prescribing physician.

The CVS on North Pleasant Street where Cunniffe works by no means evokes the Rockwellian image of the old neighborhood apothecary. Its red brick facade is stark and the aisles are crammed with stuff, including gobs of candy.

Cunniffe, 29, has been a pharmacist for six years, the last two in Amherst. It takes at least a year of being in one place to build a relationship with customers, he said, and it's that steady interaction that makes the job enjoyable.

There are elderly customers who drop by to see Cunniffe as part of their daily routine, sometimes only to update him on the Red Sox. "They know me by name and they ask how my kids are doing," he said.

In one pharmacy where he worked, a woman called in the evenings to talk about her battles with constipation. "I think she was just lonely and wanted to talk with someone. I can't get into her head but that was my impression," said Cunniffe. "A lot of what we do has very little to do with the pharmacy business. It's about being a good person."

Just as doctors and pharmacists approach the issue from different perspectives, so perhaps do pharmacists from chain stores and independents. Gregory Laham, who owns Sullivan's Pharmacy in Roslindale, questioned whether his counterparts in chains have enough time to devote to customer care and education.

The trend in the bigger stores is away from the personal touch, Laham said. "You can pump your own gas and you can check yourself out of the supermarket, but healthcare is never going to be self-service."

But a CVS spokesman, Mike DeAngelis, disputes the notion that customer care is diminishing at the 5,400 stores his company operates nationally. "Pharmacy is at the core of our business," said DeAngelis. "Seventy percent of our revenue comes from selling prescription drugs."

Regardless of where they work, pharmacists are likely to see the increasing complications of the job reflected in their paychecks. New drugs are seemingly added every day to the list of thousands pharmacists already dispense. But an aging population is creating even more demand for pharmacists. The result: With overtime, a pharmacist can make $100,000.

But Cunniffe advised against coming into the business just for the money. The job requires a long training period, about six years, and you have to enjoy serving people, he said.

As a child suffering from asthma in Jamaica Plain, Cunniffe became friends with his pharmacist, James Scanlon, who eventually hired him as an intern for four years in the late 1990s.

"Jim was always the happiest person I knew," said Cunniffe. "That's how I got into it."