Practice at the top of your license

Throughout my professional career I have many times described what it means for a pharmacist to practice at the top of their license. I often find myself justifying the extensive education we have and how it is vastly underutilized. We are more than a license hanging on a wall that allows a grocery store or big box retailer to legally have a pharmacy dispensing prescriptions. Yes, we are the medication experts. No, medications are not the only things we know about.

I have previously shared my unique experience right after being licensed of practicing in both a small community pharmacy collaborating with the attached family medicine clinic and conducting home and telephone visits managing chronic conditions. As I reflect on where my journey has taken me and how I got to where I am today, please allow me to share an experience encountered along the way and how this experience helped shaped me into the population health pharmacist I am today.

It’s less than 6 months after passing my boards. I have been shadowing another pharmacist as he performs home and phone visits with patients who have multiple comorbidities. I have been trained on the documentation process and how to bill for the services we are providing. I have been assigned a panel of 32 patients as a starting point. Over the course of two days, I have spoken with each of the patients, identified 3 drug therapy problems and documented my interactions. It’s 2006 and we are faxing our clinical communications and recommendations to the primary care providers (PCPs). No electronic medical records here.

Several days later I started receiving faxes back signed off by the PCPs. One in particular stood out. Written across a blank section of the page in all caps were the words “STOP PRACTICING MEDICINE.” To provide more perspective, the communication included a recommendation to initiate lisinopril 10mg daily for a diabetic patient with uncontrolled hypertension verified with home blood pressure monitoring. Now what do I do? I was confident the recommendation was clinically appropriate and consistent with the guidelines. I never attempted to diagnose a patient. Time to meet this provider face-to-face and see if we can work this out.

When I get to his office, I introduce myself to the front desk staff and provide a brief explanation of why I was there. She asked me to have a seat and walked to the back office. It wasn’t 10 minute later, and the PCP came into the lobby. I stood up and reached out my hand and before I could introduce myself he said, “I am reporting you to the Board of Medicine for practicing medicine without a license” and then turned and walked away. Was he serious? No further discussion. No opportunity for me to respond. Nothing. Rather than cause a scene I turned and walked out.

I reported the incident to my boss, and he took the “Let’s wait and see” approach. Maybe it was all bark and no bite. It was just over 3 weeks later, and I received a call from a Board of Medicine investigator. They had received a complaint about a pharmacist attempting to practice medicine without a license. He wanted to review all the communication I had sent to the PCP, which I promptly faxed to him. Less than 24 hours later the investigator called back and confirmed I was not practicing medicine and there would be no further investigation into the matter.

It would have been very easy for me to shy away from ever making another clinical recommendation for fear of retribution. Instead, I use the experience to demonstrate to others the importance of practicing at the top of their licenses. It can be uncomfortable at times. The opportunities it creates far outweigh the challenges that arise. I am confident the profession has progressed to a level where practicing at the top of our license is accepted and often expected. With this comes increased risk and accountability we must acknowledge and embrace as we continue to solidify our position as an integral member of the patient care team.