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Should pharmacists be allowed to immunize?

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Flu shot season has arrived and is in full swing here in Tennessee and across the nation. Immunization is one place where everyone needs to be on the same page as many of the diseases we take for granted because of immunizations killed millions on an annual basis even as late as a century ago. This year, though it comes with a new challenge to public health from the America Academy of Family Physicians, challenging the competency of pharmacists to give vaccines. You can read their position statement here and read all the holes in it below in what amounts to a cheap shot turf war over dollars at the expense of public health.

The position of the AAFP is that they should be giving immunizations and not pharmacists because AAFP physicians have more schooling and thus better education making them more equipped to deal with this complex matter of vaccine providing. They even take the time to detail all of that education they have. So sit back and strap in faithful readers, this is going to be brutal as your Intrepid Pharmacist does not take well to this political pile of equine excrement.

Before we dive in to the statement your Intrepid Pharmacist should set the following frame work on himself (And his colleagues). First, among his four degrees, one is a doctorate in pharmacy that required four additional years of education and clinical hands-on work, he not only an American Pharmacist Association certified immunizer but also one of the immunization trainers who trains and certifies other pharmacists for this particular undertaking. That is, immunizations are an additional training, but that’ snot to say they are the deep mystery the AFFP wants to pretend they are.

First off, immunizations are, in fact, nearly idiot proof in how they are structured and the nice folks at the CDC have worked very hard to make that way so the average medically untrained person on the street can figure out if he or she needs an immunization and get it. The CDC provides and updates every year charts listing who should get or consider getting what vaccines.

The charts come in two flavors: one structured by age and the other structured by disease state. This is the same chart EVERYONE uses to determine if patients should need a particular immunization. Even, you, the medically untrained, unschooled reader can look at those charts (and even the fine print footnotes on the disease state one) and determine which vaccines you should make sure you have. That is to say, this is not rocket science (that part is in the vaccine creation). Again, this goes back to that whole keeping everyone on the same page your Intrepid Pharmacist mentioned earlier. If people cannot understand the vaccines they need and why, no one is going to get them.

The AAFP physicians use the same charts that all the rest of us do, so it’s not as if they have some sort special knowledge on the subject their education has given them that none of the rest of us have (or can get for that matter).

Second, the AAFP insists the large amount of education they have will catch interactions and issues that others will not catch and that making immunizations directly available through pharmacists without physician oversight will “eliminate counseling” and put the patient at risk since pharmacists are not “prepared to collect and assess subjective and objective clinical patient information.” Only the most uneducated will buy that line (though there are plenty of those out there to buy it), for several reasons.

Reason one: vaccines interact with relatively few things. Only a couple involve allergies such as neomycin, eggs, or the like, so it's not some expansive field lke the rest of the drug world. Warfarin, a common "blood thinner", interacts with nearly everything, for instance, which brings us to…

Reason Two: all pharmacies, like physicians’ offices are required to use screening tools (this usually is a question and answer form the patient fills out), which deal with those important factors like: have you had a vaccine in the last four weeks? Are you undergoing chemotherapy or taking related drugs for cancer? Are you taking medication for immune-suppressed conditions such as transplant or HIV? And so forth. The astute link follower will have noticed a screening form on the CDC link above.

Reason Three: Other important rules, such as which vaccines have to be separated by four weeks, is part of the specialized training pharmacists receive on immunizations and the separation of particular vaccines, such as the two pneumococcal vaccines you need in your lifetime being separated by a minimum of five years, exists at part of the aforementioned reference charts the CDC updates and tinkers with every year. Interestingly, your Intrepid Pharmacist has encountered a number of cases where physicians have wrongly believed that patients are supposed to receive the pneumococcal vaccine every five years. He’s even had one argument over it. Your Intrepid Pharmacist will have to start asking about their membership affiliations.

Reason Four: If the AAFP was actually familiar with medical law they would know that pharmacists are required to counsel on new medications and vaccines are no exception. Further their outlandish claim that pharmacists are not prepared to assess subjective and objective data to make clinical assessments and drug determinations indicates a complete ignorance of what goes on in pharmacy schools. Your Intrepid Pharmacist spent 2 grueling months of his final year in school doing internal medicine at a small hospital in Durham called Duke Medical Center studying under a clinical pharmacist drug pharmacokinetics class and who made you work out that stuff by hand. To appreciate that you can see the basic formula for determining vancomycin dosing here. (And yes the use of the word “small” to describe Duke Medical Center was sarcastic—it’s practically a small city of its own. Curse you lack of a sarcasm font!)

Third, The AAFP seems to have no problem with traveling nursing companies who set up shop for a day here and there and give flu and other such vaccines in public places like supermarkets and offices. Seems odd a nurse with a bachelor’s degree doesn’t warrant the same attention as a pharmacist who has received special training on top of his advanced medical degree. Oh, but wait, technically the nurses have physician oversight. That is to say, a physically absent physician somewhere has signed off allowing them to administer vaccines to all comers who meet the criteria based on how patients answer the screening form.

And while on the subject of degrees, since 2000, the only degree available for pharmacists is the Doctorate, so the piles of graduates since then all have doctorates and many with bachelor’s degrees have gone back and completed the doctorate to remain competitive in their field. Never mind that that your Intrepid Pharmacist has never actually received a vaccine from his physician—it’s always been the nurse who gives it.

Fourth, the cherry on top of this steaming pile of equine excrement –if in fact one would actually find a cherry there—is this whole touting what wonderful highly clinically educated people the AAFP are compared to pharmacists. Really? Then AAFP people: explain this…

While doing research for his book Sugar Nation on the medical establishment’s bungling of diabetes care, author Jeff O’Connell interviewed the president of the AAFP in 2007, James King, a physician from Selmer, Tennessee no less. In the interview, which is recounted on pages 54 through 56 in the book, he said he told his diabetes patients ”to consume more carbohydrates—mainly from fruits and vegetables, not form simple sugars and starches—while decreasing the amount of meat and fat in their diet.”

For those not in the know about diabetes and sugar, carbs are definitely the enemy and they are what the body has difficulty processing when in a diabetic state, even among the obese and even when it comes from fruits instead of French fries.* As your Intrepid Pharmacist always tells his patients, it’s dark inside the body and it cannot see brands or sources, only chemical structures, and when it sees something it wants to use it has no knowledge or care where it came from, just that it fits the chemical composition required. *And lest someone get the wrong idea about the French fry-fruit comparison above, fruits are still the better choice; fries have lots of other bad compounds in them, but both are equally problematic when it comes to carbohydrate consumption.

O’Connell goes on to show what that recommendation translates into in terms of carbohydrate intake. That is, the cut in fat and meat (I.e. protein) replaces by carbohydrates (from any source) means the diabetic patient winds up taking in 12 grams of carbohydrates more than the amount of carbohydrates you receive when undergoing a metabolic stress test. And O’Connell is quick to point out such stress tests are meant to be extremes so having your patient eat like that on a daily basis is doing them no favors.

In short, the head of the AAFP just said, in print and on the record that diabetics should do the equivalent of telling a lactose intolerant patient to take more lactose or an alcoholic the best thing to help him overcome his problem is a good shot of whisky. And the meal frequency recommendations that follow are just as wrongheaded and send the diabetic patient into an insulin spike/drop cycle.

It’s nice to see all that education the AAFP touts being put to such safe and beneficial use in patient care—if the word care is even appropriate here (for the record, it’s not). If the AAFP wants people to believe that all those extra hours of education they claim to receive really make them more qualified in patient care, your Intrepid Pharmacist suggests they get their own house in order. As a both a diabetes certificate holder and bodybuilder (yes, your Intrepid Pharmacist has a non-pharmacy life as a gym rat) even he knew the AAFP’s recommendations on diabetes were wrong without O’Connell’s explanation. Still, it’s nice to see it in print (and more on Sugar Nation in an upcoming column).

In spite of its claims, the AAFP is engaging in a cheap smoke screen and throwing stones at others in the health care profession from their own glass house. The sad reality of the AAFP’s stance is that it has nothing do with education really, as demonstrated above, nor is having lots of education an apparent guarantee that you will be competent at medical care, based on the AAFP’s President’s comments on diabetes care in 2007. The AAFP’s stance is all about the dollar and the opportunity to charge an office visit and a vaccine administration fee for something that can be done by equally competent people in other venues. What is really sad is that medically untrained legislators may be mislead and seduced by faulty logic based on a few facts about total hours of education and the health of the general public may suffer for it.

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