Introduction
The World Health Organization (WHO) encourages collaboration among healthcare professionals. This approach can be used to build strong and safe health care systems that guarantee patients access to quality health services, reduce errors, and reduce health care costs [1]. The concept of collaboration among healthcare professionals comes from Lowell T. Coggeshall, who wrote in his report almost half a century ago, that the idea of medicine as a discipline used to treat one sick person should be replaced by interdisciplinary collaboration to improve and maintain the health not only of one patient, but of the entire society [2]. Elements of interprofessional collaboration include responsibility, coordination, communication, assertiveness, autonomy, and mutual trust and respect. It is this partnership that creates an interdisciplinary team to work towards common goals to improve patient outcomes [3-4].
In Poland, doctor-pharmacist cooperation is an area that requires special attention, because we are the last country in Europe to implement pharmaceutical care [5].
Despite their shared history and ethical values, there are many differences between the medical and pharmacist professions that impact patient care [6]. Currently, pharmacists and doctors are prepared to provide joint patient care. Furthermore, under the new Pharmacist Profession Act, as of 2020, pharmacists are legally obliged to provide pharmaceutical care to their patients, thus fulfilling a more patient-centric role than their traditional role of “dispensing medicines” [7].
Optimal pharmaceutical care is key to achieving therapeutic goals. To ensure this, interdisciplinary cooperation between doctors and pharmacists and/or other medical professionals is necessary [8]. Their specialized and complementary knowledge and professional experience can lead to improved patient health outcomes and may also reduce treatment costs [4].
Despite abundant evidence of the positive impact of community pharmacists on health care, in Poland, cooperation between pharmacists and doctors is often limited [7]. The COVID-19 pandemic has contributed to a change in the perception of the role of a pharmacist in the health care system [9], but these favorable circumstances have not been properly used. Pharmacists, although well trained, remain an untapped health care resource. Interdisciplinary teamwork for patients with the participation of pharmacists should be the norm in all healthcare facilities (pharmacies and clinics).
Aim of the work
This study aimed to characterize attitudes towards community pharmacist-physician collaboration and pharmaceutical care among physicians-in-training in Poland.
Material and methods
Subjects
This cross-sectional survey was conducted among physicians-in-training participating in postgraduate training courses at the School of Public Health, Center of Postgraduate Medical Education, Warsaw, Poland. Physicians undertaking specialty training in Poland are required to attend training courses on public health and medical law [10]. All 1,067 physicians attending these courses between October and December 2022 were eligible to take part in the survey. The participants represented over 40 medical specialties and different administrative regions over the country. Each participant received a link to the research questionnaire available via Google Forms. Participation in the study was voluntary and anonymous. Each participant declared informed consent before the study. The study protocol was approved by the Ethical Reviewer Board at the Center of Postgraduate Medical Education (consent number: 128/2022).
Measures
The study tool was a self-prepared questionnaire on community pharmacist-physician collaborative working and pharmaceutical care. The questionnaire was prepared based on a literature review [8,11-14] The study questionnaire included 18 questions on community pharmacist-physician collaborative working and pharmaceutical care. The questionnaire was divided into three sections: the current state of collaborative working, expectations towards collaborative working, and barriers in the widespread implementation of community pharmacist-physician collaborative working and pharmaceutical care in Poland. Questions on sociodemographic characteristics (gender, age, medical education level (having at least one specialization or undergoing first specialty training), place of primary employment, type of primary employment, and location of primary employment) were also addressed.
Results
Characteristics of the study population
Completed questionnaires were received from 509 physicians, with a response rate of 32.7%. The mean age was 32.4±6.2, median of 30 years (Table 1). Most of the respondents were female (62.7%). All respondents were physicians-in-training, but 22% had completed at least one specialization training in the past. Among the respondents, 81.1% indicated a hospital as a place of primary employment, and 88.6% indicated public medical facilities as a place of primary employment. Almost one-third of respondents (31%) worked in primary care (as a primary or additional place of employment).
Table 1
Characteristics of the study population (n=509)
Physicians’ expectations towards the physician-pharmacist collaboration and pharmaceutical care
Most of the respondents agreed (94.1%) that there is a need for physician-pharmacist collaboration and implementation of pharmaceutical care, and 89.2% believed that pharmacists can help the physicians in pharmacotherapy management (Table 2). Among the respondents, 77.2% declared a lack of knowledge of the responsibilities that community pharmacists have under Polish law; 38% of physicians declared that physicians and pharmacists trust each other and rely on their professional abilities; 79.6% declared that current medical education programs do not prepare physicians for pharmacist-physician collaborative working and pharmaceutical care.
Table 2
Physicians’ expectations towards the physician-pharmacist collaboration and pharmaceutical care (n=509)
Formal correction of the prescription was the most common reason for collaboration between physicians and pharmacists (75.6%), and approximately one-tenth of respondents declared that they currently collaborate with community pharmacists on reporting drug interactions and polypharmacy (10.2%) or drug review (9%).
Most of the physicians declared that patient education on the use of medical equipment (92.5%), detection of drugs-dietary supplements interactions (85.9%), and detection of polypharmacy (85.7%) were the pharmaceutical care services that can be provided by the community pharmacist (Table 2). Lack of IT systems supporting collaborative working and pharmaceutical care (69.5%), lack of medical education (65.2%), and lack of recommendations on community pharmacist-physician collaborative working were the most common barriers to collaboration with physicians (Table 2).
Sociodemographic differences in physicians’ expectations towards the implementation of physician-pharmacist collaboration and pharmaceutical care
Physicians who had completed at least one specialty training (83% vs. 73.6%; p=0.04), as well as those working in private institutions (87.9% vs. 74.1%; p=0.02), more often declared that they collaborated with community pharmacists during the formal correction of the prescription (Table 3). Physicians working in primary care more often declared (44.9% vs. 33.3%; p=0.01) that they collaborated with community pharmacists to modify ordered drugs (Table 3).
Table 3
The current state of community pharmacist-physician collaborative working and pharmaceutical care: physicians’ perspective (n=509)
Females more often indicated that pharmacists can be involved in patient education (94.7% vs. 88.9%; p=0.02). Physicians who indicated hospitals as a place of primary employment, compared with those working in ambulatory care, more often indicated that pharmacists can be involved in counseling on lifestyle changes (69.0% vs. 56.3%; p=0.02) and services related to polypharmacy detection (87.2% vs. 79.2%; p=0.04). Physicians working in primary care more often indicated that pharmacists may offer pharmaceutical counseling for minor health problems (45.6% vs. 36.2%; p=0.04). Moreover, physicians working in public institutions more often indicated that pharmacists may offer services related to polypharmacy detection (87.8% vs. 69.0%); p=0.001). Details are presented in Table 4.
Table 4
Physicians’ attitudes towards the pharmaceutical care services that may be provided by community pharmacists (n=509).
Males more often indicated limited time (57.4% vs. 44.5%; p=0.01) as a major barrier to collaboration with pharmacists (Table 5). Females (74.6% vs. 61.1%; p=0.001) more often indicated a lack of IT systems as a barrier to collaboration with pharmacists. Physicians who indicated ambulatory care as a primary place of employment more often indicated a lack of public funding for pharmacist-physician collaborative working and pharmaceutical care as a major barrier to collaboration with pharmacists (21.9% vs. 12.8%; p=0.02). Physicians who did not work in primary care more often indicated a lack of medical education on physician-pharmacist collaboration and pharmaceutical care (68.4% vs. 58.2%; p=0.03) as a major barrier to collaboration with pharmacists (Table 5).
Table 5
Major barriers to the implementation of community pharmacist-physician collaborative working and pharmaceutical care
Discussion
The presented study shows three areas of cooperation between doctors undergoing specialist training and community pharmacists: their current cooperation, barriers, and expectations. The results indicate that currently as many as 94.1% of doctors see a clear need to cooperate with pharmacists and the need to implement pharmaceutical care. This is related to the heavy workload of Polish doctors, especially in primary care. Compared with doctors from other European countries, they have a much larger number of visits, which leads to the need to shorten the consultations’ time [15].
However, it is difficult to develop this cooperation if 77.2% of doctors undergoing specialist training admit that they do not know the competences of pharmacists under the Act on the Pharmacist’s Profession [16], and as many as 13.2% have no opinion on this subject. Doctors don’t know what to expect from pharmacists, and the changes are fundamental. The new Act on the Profession of Pharmacist divides the areas of professional activity of a pharmacist into four categories, i.e., providing pharmaceutical care, providing pharmaceutical services, performing specific professional tasks, and performing other activities [16].
The period of specialization training of doctors is the best time for the doctor to obtain information about the pharmacist’s competences. Research from the state of California shows that interprofessional collaboration should start in college. Lectures on the use of drugs given by pharmacy students filled the knowledge gaps of medical students, nurses and physician assistants, resident physicians and other medical workers [17], and at the same time showed that cooperation between professions is mutually beneficial [18]. Meanwhile, the presented study shows that as many as 79.6% of doctors undergoing specialization training stated that current education programs do not prepare doctors for cooperation with pharmacists and pharmaceutical care.
Analyzes from Germany show that the most effective form of shaping this cooperation is joint learning between students of various medical faculties at the patient’s bedside or case studies [19]. As many as 65.2% of doctors participating in specialization training indicated that cooperation between doctors and pharmacists should be included in medical education programs.
This lack of knowledge about the competences of Polish pharmacists means that currently 75.6% of doctors’ contacts are limited only to corrections of the formal prescription (e.g., change of drug dosage) and 36.9% to modifications of ordered drugs (e.g. resulting from incorrect dosage, blocking of the active substance or unavailability of the drug on the market). Only about one-tenth of physicians in specialty training collaborate with pharmacists in reporting drug interactions and polypharmacy (10.2%) or reviewing medications (9%).
An important result of the presented study is that 31.8% of doctors, during specialization training, asked pharmacists for help in prescribing prescription drugs that are better suited to the individual needs of a specific patient, including adjusting the dose or concentration of the active substance to age.
However, this is a very narrow scope of cooperation, and the potential and knowledge of Polish pharmacists is not properly used. It is worth emphasizing that other countries had similar experiences when they introduced pharmaceutical care in the early 1990s, e.g., in Iceland [20]. Currently, however, the cooperation of Icelandic doctors and community pharmacists concerns only practical clinical issues, and the comments of Icelandic pharmacists are accepted by GPs in 90.3% of cases [20]. Similarly in the USA, where both professional groups positively assessed the pharmacist’s assistance in detecting drug interactions [21].
As many as 38% of survey respondents believe that the current regulations of the health care system in Poland do not allow cooperation between pharmacists and doctors, and 20.6% have no opinion on this matter. There are different system solutions in many countries. For example, thanks to E-Systems, doctors and pharmacists play an important role in ensuring the safety and appropriate treatment of patients by avoiding drug interactions [22]. Moreover, in Australia, pharmacists can offer many services that are attractive to patients, such as vaccinations, blood tests and medical certificates for excused absence from work [23]. Most of the above services are also possible under the Polish Act on the profession of pharmacist. Importantly, pharmaceutical care is currently a part of the national health service [24] and an element of comprehensive patient care.
Doctors expect support in patient care in various fields. According to the presented study, most doctors declared that the area of pharmacists’ support should include patient education in the use of medical equipment (92.5%). A practical example here is adult-onset diabetes. A nationwide cross-sectional study shows that patients already diagnosed with diabetes still have significant gaps in knowledge about this disease. For this reason, primary care physicians, internists and diabetologists [25], and community pharmacists should be actively involved in the education of patients at increased risk of diabetes.
The results of American studies indicate that pharmacist intervention improves control of glucose level [26]. In this study, 89.2% of physicians noted that a community pharmacist can help them manage pharmacotherapy, which involves selecting the optimal treatment based on reliable and up-to-date scientific evidence (evidence-based health care (EBHC)) [27] and improving the patient’s quality of life [28].
According to 87.8% of respondents, patients visiting primary care physicians will benefit most from cooperation between doctors and pharmacists. This is confirmed by the ambulatory care model in the USA, where cooperation with pharmacists has improved patient health outcomes, quality of care, and reduced health care costs [29]. Among other patient groups that can benefit from the cooperation of doctors and pharmacists, respondents mentioned: patients visiting specialist clinics – 43.6%; and patients undergoing hospital treatment – 37.9%.
Doctors training in this specialization indicated certain areas requiring changes that facilitate cooperation between doctors and pharmacists. The Act on the profession of pharmacist does not specify how and on what terms cooperation between a pharmacist and a doctor should exist, thus leaving room for inconsistency. Doctors prefer a formal framework for collaboration. As many as 91.6% of respondents indicated the need to develop guidelines and recommendations regarding cooperation between doctors and pharmacists.
For 70.1% of respondents, financing cooperation between doctors and pharmacists from public funds was of key importance. In many countries, such financing has accelerated the development of pharmaceutical care. A further barrier indicated by doctors training in this specialization was the lack of IT systems supporting cooperation and pharmaceutical care (69.5%).
Trust is an integral part of effective cross-industry collaboration. In the presented study, respondents were divided into three groups. The first and largest group of respondents expressed the opinion that doctors and pharmacists trust each other (definitely yes 2.2% and rather yes 35.8%). The second disagreed (not 3.5% and probably not 29.5%), and the third had no task on this topic (29.1%). The above division may result from the parallel discussion among young doctors regarding the no fault system and the Act on Quality and Patient Safety [30]. According to young doctors, it is important to build a culture of safety [31]. Building a culture of safety also means people providing health services getting to know each other, working together, and creating mutual trust [32].
This study provides specific guidance for future interprofessional collaboration. The results of this study will be beneficial for pharmacists and doctors, researchers, and decision-makers who want to introduce changes in the Polish health care system. The idea is to build a system that is safe for the patient and guarantees high-quality services based on cooperation between the doctor and the pharmacist.
The strength of our study is the large study sample on which we evaluated the cooperation of the pharmacist doctor. The Center for Postgraduate Medical Education is an entity that deals with postgraduate education of physicians from all over the country.
The current study has some limitations. Participants were recruited from physicians who participated in specialty training in mandatory courses in medical law and public health. Therefore, the analysis lacks clear differences in physicians’ attitudes toward current collaboration with pharmacists and barriers according to gender, age, seniority, specialization obtained, and workplace size. Future studies should recruit participants from more diverse medical entities to address this concept.
Conclusions
The study shows that current cooperation between doctors and community pharmacists is limited to formal issues. Building cooperation between doctors and pharmacists must start at the education stage. Educational programs should be modified in such a way that doctors learn about the statutory capabilities and competences of pharmacists and prepare in a practical way for future cooperation by building mutual relationships based on trust. Doctors point to specific barriers that inhibit doctor-pharmacist cooperation. The most important of these are the development of recommendations. Recommendations should first cover the most critical areas of support for doctors, i.e., patient education and pharmacotherapy. The implementation of pharmaceutical care should start with the cooperation of primary care physicians and community pharmacists from available pharmacies.
