JULY ,Edition # 30, 2001

Payment for community based medication reviews by pharmacists were introduced by the Department of Veterans' Affairs in 1998.
Like the proposed Domiciliary Medication Management Review (DMMR) initiative recently proposed, DVA made reviews dependent on a doctor's referral to the consultant pharmacist.
It was my opinion at the time that this factor would prove to be a stumbling block and that the medical profession would be unwilling to have any other group review its prescribing practice. Unfortunately I was proved correct and very few veteran patients have had access to reviews by specialist consultant pharmacists.
I have struggled over the intervening years to understand the differences in pharmacist/doctor relations that are evident between hospital and community practice.
The Health Team concept of patient care was already evident in Australian hospitals as far back as 1974 when I first became a hospital pharmacist. Consultations between doctors and pharmacists are a fact of life in the modern hospital with both professions recognising the others area of expertise.
Why, given that the majority of Australian doctors have worked in this collaborative style during their internships, does this team style of patient care not continue into the community?
Doctors who seem quite at ease with pharmacist input to medical care while in the hospitals become hostile to it in relation to medication management reviews in the community. There are, I am sure, a number of plausible explanations that come to mind to explain this change but, at this time, I will concentrate on only two that I consider relevant.
The first of these is the medical profession's view on the manner in which the government introduced medication reviews.
The introduction might have been handled with a little more care but there appeared to be a misconception among doctors, reinforced by the medical press, that these strategies were imposed on them without consultation.
This belief, whilst it was incorrect (DVA having negotiated extensively with major medical divisions), could be an explanation for the antagonism that eventuated.
I remember reading, with growing annoyance, editorials and letters accusing pharmacists of everything from incompetence to wanting to supplant doctors as the primary supplier of health care.
The question was raised as to why pharmacists would receive payment for something they should have already been doing. One letter even made the suggestion that part of the fee paid by DVA to the pharmacist should be passed on to the referring doctor!
It is not surprising that, with this as the official" view of medication management reviews by pharmacists, doctors have been less than enthusiastic about referring DVA patients. It is my worry that this negativity will carry over to the new DMMR programme.
We, as a profession, want to be thought of as part of the health care team and treated as such.
Discussions with doctors in the Osborne and Fremantle Divisions of General Practice indicate another possible barrier. This one is of concern to me and may be even more difficult for our profession to overcome.
I am speaking of the experiences, in many cases unpleasant, these doctors have had in relation to medication reviews in nursing homes. In many cases the first time a doctor knew anything about his/her nursing home patients being reviewed by a pharmacist was when a letter arrived "telling them what they had done wrong in their prescribing"!
How on earth can we expect doctors to treat us as professional equals if we don't return the compliment?
In a recent course I attended, one of the sessions concentrated on how to develop a good working relationship between consultant pharmacists and medical practitioners.
Jeff Hughes, a Curtin University lecturer, pharmacy proprietor and accredited consultant pharmacist, described his approach in this matter.
This consists of introducing himself, highlighting his credentials and experience, describing how he hopes to assist the doctor to give high quality drug therapy and then, only then, making suggestions for change.
Jeff is very insistent that the report to the doctor concentrates only on CLINICALLY relevant medication problems that might be addressed, and that these should be prioritized for the doctor. He finds that this type of approach defuses most situations and increases the prospects for a fruitful professional relationship. How different is this from the scenario I described above.
Is it any wonder that Jeff is much in demand to carry out medication reviews in nursing homes?
Until all of our contact is carried out in such a professional manner I foresee continued antagonism and a less than optimal relationship.

Note that the views expressed in this column are my own and may not reflect those of the Department.
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