Pharm World Sci (2007) 29:574–576 DOI 10.1007/s11096-007-9130-2
COMMENTARY
Exploring elements of interprofessional collaboration between pharmacists and physicians in medication review Timothy F. Chen Æ Abilio C. de Almeida Neto
Received: 13 October 2006 / Accepted: 2 April 2007 / Published online: 4 May 2007 Springer Science+Business Media B.V. 2007
Abstract In medication review involving community pharmacists and physicians, there is an underlying assumption that if community pharmacists provide evidence based pharmacotherapeutic recommendations, physicians, in turn, will implement these recommendations. However, although in general medication review has been shown to improve the quality of medicine use, medication management plans arising from the medication review process are not always implemented. There is a need for better understanding of the factors that influence outcomes in medication review. The current paper will address some cultural and procedural factors that may assist in understanding outcomes in medication review using research into collaboration from areas outside the healthcare as a framework. Keywords Medication review Interprofessional collaboration Community pharmacist Physician Trust In a worldwide trend, policy makers are investing in medication review programmes involving community pharmacists and physicians, aimed at improving the quality and safety of medicine use. Although there are different components of medication review programmes, some of the key elements of medication review include a structured critical examination of a patient’s medicines with the goal to maximise an individual patient’s benefit from their medication regimen [1, 2]. After conducting the medication
T. F. Chen A. C. de Almeida Neto (&) Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia e-mail:
[email protected]
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review, the pharmacist then writes a report, which may contain pharmacotherapeutic recommendations, and sends it to patient’s physician [1, 3]. Usually, after discussing the medication review with the pharmacist, the physician and patient agree on a medication management plan [1, 3]. As both, physicians and community pharmacists, have specialist knowledge of medicines, it makes sense for both professionals to collaborate. It is true that the literature reports positive results on patient health outcomes arising from this collaboration [4]. However, it could be the case that some factors that may influence the outcome of interprofessional collaboration are at times overlooked in medication review programmes. Currently in the medication review process, there is an underlying assumption that if community pharmacists provide evidence based pharmacotherapeutic recommendations, physicians, in turn, will implement these recommendations. However, although in general medication review has been shown to improve the quality of medicine use [5, 6], medication management plans arising from the medication review process are not always implemented [6]. There is a need for better understanding of the factors that influence the outcome of medication reviews. The current paper will address some cultural and procedural factors that may assist in understanding outcomes of medication review using research into collaboration from areas outside healthcare as a framework.
Some significant elements of successful collaboration Research provided elements from the
conducted outside the healthcare setting has insight into some cultural and procedural that facilitates successful collaboration. Studies commercial world have demonstrated that for
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collaborative efforts to be successful, the expectations and practice of collaboration must exist prior to the introduction of innovative collaborative ventures [7, 8]. That is, the introduction of collaborative efforts alone may not be sufficient to induce effective collaboration. A good example is the introduction of software designed to help teams or groups of people work together in commercial organisations: it was found that software that promotes sharing of information with others doing similar work does not necessarily enhance collaborative efforts [9]. A strong internal culture of sharing seems to be necessary for members of an organisation to successfully collaborate with others, either from within or from outside the organisation [8, 10]. In organisations with such a culture, collaboration with others is just an extension of the way they already operate [10]. We believe that many of the basic elements of effective collaboration and teamwork are universal and may also apply to the healthcare setting. That is, the expectation and practice of collaboration must also exist in the healthcare setting for collaborative efforts among healthcare providers to be optimal. Although the nature and extent of physician-community pharmacist collaboration vary a great deal in different healthcare settings, overall a strong expectation of collaboration seems to be the exception rather than the norm for routine practice between the two healthcare providers. Although there are some excellent examples of effective collaboration between physicians and community pharmacists [4–6], it is true that typically in healthcare systems collaboration between the two healthcare providers has been episodic and informal rather than of a continual nature. When interactions between community pharmacists and physicians do occur, usually they tend to be via telephone and relate to a specific pharmacotherapeutic issue rather than as part of a continuum of care [11].
Current barriers to successful collaboration Medication review has provided physicians and community pharmacists with a valuable framework for collaboration, which has the potential to improve the quality and safety of medicine use. However, the implementation of medication review programmes alone may not necessarily result in effective collaboration unless there are clear-shared expectations of collaboration by both community pharmacists and physicians prior to the introduction of the service [11–13]. Indeed, given the historical lack of close collaboration, it might be difficult for physicians to accept that they can utilise the expertise of community pharmacists to improve the quality and safety of medicine use. Hence, there are significant cultural barriers to be overcome for medication review services involving
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community pharmacists and physicians to lead to consistent successful outcomes. We need to build a culture in our healthcare system that fosters expectations and practice of collaboration between the two healthcare providers. The lack of routine face-to-face interactions between physicians and community pharmacists may be a significant barrier to a culture that supports collaboration between the two healthcare providers. It is true to say that in some cases, a significant proportion of medication reviews are undertaken by physicians and community pharmacists not only operating separately from each other [14] but also with very limited history of face-to-face interaction. Indeed, it is common for community pharmacists and physicians to provide information to each other in an impersonal and asynchronous manner through written reports rather than in a face-to-face fashion. In contrast, in the commercial world it is recognised that in situations where team members work separately from each other, initial face-to-face meetings are especially critical for effective teamwork [15, 16]. Team members need to trust that the information they receive from each other is accurate and reliable and face-to-face interaction is seen as an essential element for establishing trusting relationships in teamwork [17, 18]. We believe that, as in the commercial world, face-to-face interaction facilitates the establishment of trust, making it easier for physicians to accept information provided by community pharmacists in the medication review process. Indeed, throughout evolution, for hundred of thousands of years, we, humans, have been using interpersonal cues conveyed in face-to-face interactions to make judgements about trust [15]. Furthermore, common sense tells us that it is not wise to trust people we do not know [17]. Factors that facilitate the establishment of trust between community pharmacists and physicians must be taken into account in the medication review process, if this collaboration is to be optimised. We must not forget that trust is the basis for cooperation and that quality of interaction is dependent on trust [16].
Establishing a culture of collaboration Given that in general the prevailing culture of healthcare systems does not inherently support close collaboration between physicians and community pharmacists, building mutual trust by bringing the two healthcare providers face-to-face to discuss and plan actions arising from the medication review process would represent an important step towards cultural evolution and a major step towards consistent successful outcomes in medication review.
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Concluding remarks We recognise that lack of clear-shared expectation of collaboration by community pharmacists and physicians and the lack of routine face-to-face interactions are by no means the only barriers that need to be addressed in the process of medication review. In the current paper we merely focused on outlining practices that are commonly acknowledged to affect the success of collaborative efforts outside the healthcare setting that may also apply to collaboration between community pharmacists and physicians in the context of medication review. We trust that this paper will encourage others to pursue more work on the determinants of successful collaboration in medication review.
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