Clinical pharmacist: from behind the scenes to the front
China News Weekly reporter/Yuan Suwen
Issued in the 1022th issue of China News Weekly on November 29, 2021
In the spacious outpatient hall of Huilongguan District of Jishuitan Hospital, there are 10 open windows for medicine. Patients gather in front of the windows, and after calling the number, they hand in prescriptions with one hand and take medicines with the other.
The window is the main body of the pharmacy. In the original design, the pharmacy may not consider functions other than the distribution of medicines.
But now, a door opened at the end of the pharmacy with the words "Medication Counseling Center" written on it. Two pharmacists left the army of distributing medicines and sat at the table to visit for free.
During the three hours in the afternoon of October 17, Li Quanzhi, the chief pharmacist of Jishuitan Hospital, received a total of 12 patients.
After graduating from graduate school, Li Quanzhi worked at this desk for 10 years. He was not satisfied with mechanically training patients on how to use medicines correctly. He hoped to explore and analyze the cause of disease and optimize patients' medication regimens.
"I am out of a pharmacy clinic." He said, "Drug consultation is only part of it."
On October 13, the National Health Commission issued the "Notice on Printing and Distributing 5 Norms of Pharmacy Outpatient Service Standards in Medical Institutions" (hereinafter referred to as "Normations"), which provided pharmacists in pharmacy outpatient clinics, drug reorganization, medication education, pharmaceutical care, and home The five aspects of pharmacy services have been standardized. This is the first time that the job responsibilities of pharmacists have been clarified.
But this may be just the beginning. Due to insufficient staff and no charging standards, pharmacy clinics are still not widely recognized in Chinese hospitals.
Zhen Jiancun, chairman of the Pharmaceutical Affairs Committee of the Chinese Hospital Association and director of the Pharmaceutical Department of Beijing Jishuitan Hospital, participated in the drafting of the above specifications. She told China News Weekly that since 2005 A total of 17,089 clinical pharmacists have been trained, mainly in the top three hospitals in developed areas.
"China's development is uneven, and I hope that these standards will become a ruler, so that all places can reach 60 points."
What does the pharmacy clinic do?
Pharmacy outpatient clinics are not popular in China, even in the top three grade A hospitals with a high level of development.
According to the "2019 China Health Statistics Yearbook", there are 1,442 Class-A hospitals across the country.
In May 2021, the paper “Online Survey on the Establishment of Pharmacy Clinics in Top-A-Class Hospitals in China” (hereinafter referred to as “Pharmacy Clinic Survey”) was published in the Chinese Journal of Pharmacy in May 2021. There are 172 companies, accounting for 12.97%.
Unlike clinicians, pharmacists are medical technicians, but after Li Quanzhi entered the hospital, he still got two years of standardized training opportunities.
After the training, he chose to stay in the Endocrinology Department.
Every Wednesday afternoon from 1:30 to 4:30 in the afternoon, he and an endocrinologist go out to the joint outpatient clinic. The patients who come to him for consultation are all recommended after consultation by the specialist.
On the afternoon of October 17, Li Quanzhi received a total of 12 patients for three hours. Their conditions were divided into three categories: diabetes, asthma or chronic obstructive pulmonary disease, and osteoporosis.
Among diabetic patients, some have doubts about changing new medicines, and some are worried about the sudden need to add medicines. They carefully inquire about diet control methods, and those with serious illnesses come to consult with various insulin injections.
In the face of asthma or COPD patients, they are mainly trained to use hormone-containing inhalants and reminded to finish gargle to prevent hormones from harming the oral mucosa.
As for certain types of drugs for osteoporosis patients, you need to stand upright after taking it, otherwise it may damage the esophagus. These require special reminders.
In addition to explaining the usage of medicines, during the average 15 minutes of face-to-face with each patient, Li Quanzhi also asked about their medical history, looked through the laboratory test sheet, and made suggestions for the patient-supplementing the doctors who have too many patients and limited time. Unable to give attention.
Diabetes management is Li Quanzhi's specialty.
An elderly man in his seventies came to consult with the insulin prescribed in a secondary hospital. In the secondary hospital, the cardiologist prescribed him 20 insulins of a certain brand, but Li Quanzhi saw the box and found that it was a kind of targeted treatment. The premixed insulin used by young people is not suitable for the elderly.
The old man told reporters that before, "Little Li" recommended him two combinations of insulin, and his blood sugar has been stable after using it.
Later, when one of the medicines ran out, he went to the second-level hospital in front of his house to prescribe the medicine. Unexpectedly, the doctor prescribed the wrong medicine.
"There are many insulin brands on the market now, and it's normal for doctors to be confused." Li Quanzhi turned on the computer and showed the four types of insulin he summarized. Each insulin has three or four models, with onset time, peak time and duration of action. Time is different. Based on these data, he helps patients calculate the time of medication, meal and exercise.
In the days when he was not going to the clinic, Li Quanzhi gave the doctor's advice on the interdisciplinary medication.
"I know antibiotics better than doctors who specialize in infectious diseases." He used this analogy.
"Without my position, if a doctor encounters drugs in other disciplines, he may have to consult with other doctors, but with the presence of a clinical pharmacist, basic interdisciplinary medication problems can be solved."
Li Quanzhi pointed out that foreign studies have shown that the involvement of clinical pharmacists in chronic disease management of type 2 diabetes can reduce the glycosylated hemoglobin of patients in the intervention group by 1.7% more than those in the control group.
The figure for domestic research is 1.1%.
According to his own research in 2019, after a clinical pharmacist followed up community type 2 diabetes patients for six months, the A1C of the intervention group was 1.5% lower than that of the control group.
Domestic pharmacists can participate in relevant training and obtain clinical pharmacist certification.
According to Zhen Jiancun, today’s clinical pharmacist training is divided into general subjects and specialties. The specialization is one year and is divided into 20 specialties. Some specialties focus on drugs, such as anti-infective drugs, anticoagulants, anti-tumor drugs, and enteral medicine. And parenteral nutrition; some majors start from diseases, such as cardiovascular medicine, endocrinology, and respiratory medicine; others are divided by population, such as obstetrics and gynecology, pediatrics, etc. "These 20 majors basically cover all clinical Professional needs, but there are currently no regulations that require pharmacists to undergo training before they can go to the clinic. There are some untrained pharmacists with older qualifications that are also working in the clinic. We call this "old methods for the elderly, new methods for newcomers"."
According to the "Pharmacy Clinic Survey", there are obvious differences in the development of pharmacy clinics in different regions, which may be related to the development level of local clinical pharmacy and the government's attention.
In the more developed Guangdong, Beijing, Zhejiang, Jiangsu and Shanghai, the number of Class-A hospitals that have opened pharmacy clinics accounted for 18.94% of the total number of Class-A hospitals in the region, while in the western and central regions, the figures were only 8.81% and 6.75%, respectively.
Zhen Jiancun pointed out, "The main responsibility of doctors is diagnosis, and the main responsibility of pharmacists is to understand medicine. The main responsibility of pharmacists is to treat drugs and understand medicine. At the same time, patients have many pathological, physical and psychological needs after being treated. , Doctors and pharmacists should serve patients in a team manner, and each give full play to their professional advantages in order to get the best results."
What does a clinical pharmacist do
A major role of clinical pharmacists is to improve the level of rational drug use.
In a county in the southwestern part of Shandong Province, nearly 600 kilometers away from Beijing, Li Hong (pseudonym) is the director of the newly established “Clinical Pharmacy Department” of a secondary hospital. The two received clinical pharmacist training.
She told reporters that the main reason why they established the clinical medicine department last year was that the hospital was striving to be promoted to the second class, and "rational use of drugs" was one of the evaluation criteria.
She recalled the previous failed review.
At that time, the hospital expanded the building and purchased good equipment, but after the review experts arrived, they only checked the medical records and concluded that "the difference is too far."
The medical record records the antibacterial drugs prescribed by this hospital to patients, "there is no concept of controlling the intensity of antibacterial drugs." Li Hong said.
Antibacterial drug abuse can lead to drug resistance and cause adverse reactions, but in the hospital where Li Hong works, doctors often use two or three types of antibacterial drugs in combination, which is "extraordinarily messy." She said that after the establishment of clinical pharmacy, two clinical pharmacists regularly summarize medical records Prescribes, collects adverse reactions, finds medication problems, and she is responsible for training doctors on medication.
Clinically, the phenomenon of improper use of drugs is very common, and the damage caused may be huge.
In the compulsory course of the American Doctor of Pharmacy and the authoritative book "Practical Methods of Pharmaceutical Care: Patient-centered Drug Therapy Management Services", it points out the morbidity, mortality, and high costs associated with drugs.
In 1997, the cost of drug-related diseases in the United States could be as high as $136 billion.
Among preventable drug-related hospitalization problems, prescription problems accounted for 30.6%, compliance problems accounted for 33.3%, and monitoring problems accounted for 22.2%.
A 2003 study in the United States showed that adverse drug reactions and other drug-related problems have increased the cost of health care in the United States by more than $200 billion.
In addition, 37% of avoidable medication errors were dose errors, 11% were drug allergies or drug interactions, 22% occurred during hospitalization, 66% occurred during “medical referral”, and 12 % Occurred during discharge.
"Misdispensing errors are a major cause of this problem. We found that there are about 100 undetected dispensing errors every day." A 2006 study in the United States showed that 10.7% of elderly people admitted to the hospital may be due to adverse drug reactions. Caused.
To solve this problem, an important job of American clinical pharmacists is to review prescriptions in advance.
According to Lu Yun, a professor of clinical pharmacy at the Haipeng Medical Group of the University of Minnesota School of Medicine in the country, in the computer system of the hospital, the prescriptions issued by the doctors are first put into the database and then reviewed by the pharmacist before the medicines can be distributed. If you pass, you won’t be able to go to the next link.” Lu Yun recalled that because there were a large number of pharmacists, the early review of each prescription would not reduce efficiency.
In the emergency rescue, the doctor and the pharmacist form a team, the doctor verbally issues a medical order, the pharmacist handles it immediately, and the medicine can be taken through a special channel.
"Of course, all procedures are expedited during the emergency rescue."
Lu Yun told China News Weekly that as early as the 1990s, there was no fee standard for outpatient pharmacy in the United States, but doctors of pharmacy were very popular with inpatient doctors at that time.
At that time, the medical insurance policy for inpatients in the United States was "Drug Packaged Payment" (DRG). Pharmacists could maximize the effectiveness of drugs, control the side effects of drugs, and reduce drug consumption and cost savings.
"An obvious example is that if a pharmacist goes on vacation and the doctor can't find a medical staff, the cost of medicine in the ward will go up all at once. The hospital finds that it can reduce consumption, which gives the motivation to hire a clinical pharmacist."
In 2002, China proposed to gradually establish a clinical pharmacist system in medical institutions.
With the deepening of medical reform, the importance of clinical pharmacists began to become prominent.
In 2017, the "zero mark-up for drugs" policy was introduced, making the cost control problem of hospitals urgent.
Zhen Jiancun pointed out that more than half of the medical insurance costs are spent on drugs. The key to medical insurance cost control is to allow pharmacists to control the rational use of drugs and save costs.
On July 10, 2018, the National Health Commission and other three departments jointly issued the "Regulations for Prescription Review of Medical Institutions", which proposed that "pharmacists are the first person responsible for prescription review" and required "all prescriptions (including outpatient prescriptions and medical prescriptions). District doctor’s order form) shall be reviewed and approved before entering the link of pricing, charging and deployment, and prescriptions that have not been reviewed and approved shall not be charged and deployed".
But the problem is that due to China's vast territory, large gaps in the level of medical institutions, and extremely scarce pharmacists, it is currently impossible to manually review prescriptions in advance.
Zhen Jiancun said that at present, when prescriptions are issued in most of the top three hospitals in Beijing, they are reviewed by the software, and then the prescription reviews will be carried out.
Zhen Jiancun is the regional prescription review leader of the Beijing Medical Management Center, and he also leads the national prescription review testing.
She said that since 2014, she convened forty to fifty experts every year to conduct two concentrated prescription reviews, that is, to collect prescriptions from various hospitals, clean the data and form white prescriptions, and then comment on their contents.
The Beijing Municipal Medical Management Center included the prescription qualification rate into the hospital’s performance appraisal indicators.
An expert who participated in prescription reviews revealed that based on the prescriptions he has seen, the problem prescription rate is 12% to 16%, and each prescription may have multiple problems.
In the initial prescription reviews, there were more general and basic irregularities, and later it was more specific.
"For example, some doctors only wrote about injections, but did not specify how the injections should be made. Is it subcutaneous, intradermal or intravenous? Is intravenous injection a bolus or drip?"
Scarce pharmaceutical talents and unrecognized value
As early as 2000, Lu Yun introduced the concept of clinical pharmacists to China.
She recalled that at the time she felt that there was a 20-year gap between China and the United States, but she saw the rapid growth and progress of clinical pharmacy in China in recent years, "this gap is rapidly narrowing".
However, there is still a huge gap in the number of employees.
Lu Yun said that she has calculated that the average number of clinical pharmacists in China and the United States is nearly a hundred times different.
She gave an example of the hospital where she worked. The affiliated hospital of the University of Minnesota School of Medicine has 460-480 beds and more than 100 clinical pharmacists, including about 50 in the inpatient department, about 20 in the outpatient department, and about 20 in mobile positions. .
Jishuitan Hospital has a total of more than 1,700 beds. The number of pharmacy outpatient registrations ranks first in Beijing, but the number of clinical pharmacists is still a huge gap with Lu Yun's hospital.
Zhen Jiancun told reporters that she manages a total of 84 people in the pharmacy department, of which 21 are specially trained clinical pharmacists, but these 21 people are distributed in different departments. Some have junior professional titles and are not qualified enough to go to the clinic, such as the clinical department of Critical Care Medicine. Pharmacists do not have outpatient clinics. At present, only the endocrinology, cardiovascular, respiratory, digestive and neurology departments are out of pharmacy outpatient clinics.
"Our hospital has three campuses. It is very difficult to have clinical pharmacists visiting every day." She said.
High-end talents in clinical pharmacy in China are still scarce.
Shi Luwen, director of the Department of Pharmaceutical Affairs and Clinical Pharmacy, Peking University School of Pharmacy, said that since 2003, Peking University School of Medicine has begun to pilot a master's degree in clinical pharmacy and cultivate a master's degree in clinical pharmacy. After that, it was the first to conduct a doctoral pilot. Nowadays, two doctors have graduated. This year, "add up to ten people."
He looks forward to the establishment and promotion of a rational drug use system in various hospitals for this batch of doctoral students like "a single spark" in the future, but from a realistic point of view, this is not easy.
"Think about it, why is it called a pilot? Breaking the original interest pattern is called a pilot."
According to Shi Luwen, in the 1990s, West China University of Medical Sciences first launched the clinical pharmacy major and began to train undergraduates, but it was interrupted after a few years.
"Because the country paid more attention to promoting and speeding up the imitation of drugs, and did not fully pay attention to the rational use of drugs, the training of pharmacy talents at that time was more inclined to the traditional chemical model, allowing them to quickly produce these generic drugs." Four universities, China Pharmaceutical University, Tianjin University of Traditional Chinese Medicine, Dalian Medical University, and Harbin Medical University offer clinical pharmacy majors.
According to the 2021 college admissions catalog, 46 colleges and universities currently offer undergraduate clinical pharmacy majors.
"It is now advocating that generic drugs change to original research drugs. If pharmacists have no clinical experience, it will also affect the development of innovative drugs." Shi Luwen believes that the training of Chinese pharmacy talents is still mainly for the pharmaceutical industry. Healthy and rational drug use talents are an international development trend."
But at the moment, the universal free outpatient service means that the labor value of clinical pharmacists is not widely recognized.
According to the "Pharmacy Clinic Survey", among the 172 tertiary hospitals with pharmacy clinics, 21 hospitals do not charge registration fees or consultation fees for pharmacy clinics, and 75 hospitals charge corresponding registration fees or consultation fees at specific pharmacy clinics. , The other 76 hospitals were unable to obtain detailed charging information.
Currently, there is no national fee standard for pharmacy services, but some places have taken the lead.
For example, in 2018, the Guangdong Provincial Health Commission issued the "Notice on Strengthening the Management of Pharmaceutical Affairs and Drug Control in Medical Institutions and Promoting the High-quality Development of Pharmaceutical Services", which clearly stated that it is necessary to actively promote the establishment of pharmaceutical service fees.
Zhen Jiancun said that pharmacy services can improve the efficiency of the use of medical insurance costs and save medical insurance funds. "I hope that medical insurance can provide a reasonable compensation for pharmacy costs."
China News Weekly, Issue 44, 2021
Statement: The publication of the "China News Weekly" manuscript is authorized in writing