The end of pharmacists as we know them

The lie of the land in pharmacy is changing. And the rate of that change is accelerating.

Are you onboard or are you protecting your ‘expert’ turf that you have been cultivating all these years?

I first spoke to Professor Zubin Austin in early 2020 and to be honest I found him to be a captivating, eloquent and frankly inspirational pharmacist.

Cautious, procrastinating perfectionist, low tolerance for ambiguity.

Ring any bells?

Zubin has provided significant thought leadership in this area and has contributed many suggestions on how we cope with potentially saying goodbye to the type of pharmacist we used to know.

At Pharmacy in Practice, we are delighted that he has agreed to make the trip from Toronto to address delegates at the inaugural Pharmacy in Practice conference in Edinburgh in May 2024. Zubin will deliver the inaugural Pharmacy in Practice Annual Lecture.

Zubin’s research examines some of the challenges in implementing changes in pharmacy practice, such as extending prescriptions and offering new services. He explores whether these challenges stem from pharmacists’ innate personality traits or the culture within the pharmacy profession. He raises concerns about whether the right candidates are entering the pharmacy profession.

He also delves into the personality traits of practising pharmacists, emphasizing traits like ‘agreeableness, conscientiousness, and openness’. Zubin has suggested that due to these traits, many pharmacists actively avoid making decisions and that this could be contrary to the image of a caring and progressive profession. He has said that professional culture in pharmacy may not align with the goal of patient-centred care, impacting the integration of advanced services.

He indicates the need for knowledge translation and change management strategies to reshape the future of pharmacy practice. ⁽¹⁾

So many of the themes highlighted so brilliantly by Zubin are at the core of what the profession of pharmacy is now grappling with. Advanced practice, independent prescribing and a difficult operating healthcare environment.

In early 2020 I sat down with Zubin to have a fascinating conversation. I didn’t know it at the time but the content of this conversation would shape the long run into our inaugural conference. I want to celebrate excellence in pharmaceutical care in Scotland but before we do that during #PIPLIVE2024 we need to start with the existential stuff.

What is a pharmacist?

What is our collective purpose?

What is our duty to regulators and to the people we care for?

As pharmacists are we actually hindering our own progress?

What changes are required to flourish as a profession with the myriad challenges that face us?

So with these thoughts lingering, I want to take you back to early February 2020, before the pandemic and before tumultuous change was thrust upon us. I hope that by reading Zubin’s words you will be enthused to join pharmacy friends and colleagues across all sectors of Scotland to reflect on what we have gone through recently, celebrate the excellence in pharmaceutical care delivered on a daily basis across Scotland and discuss robustly where our profession goes next.

Interview with Professor Zubin Austin originally published February 2020.

Zubin, in your view what is a pharmacist?

“There are several ways to approach it. For many pharmacists reading this, their instinctual response might be to think of a pharmacist in terms of their legal scope of practice, a definition rooted in regulations, or some historical pattern of behaviours traditionally associated with pharmacy. All of those are perfectly legitimate. They are probably the easiest ways to think of or define a pharmacist. However, they don’t fully capture the wide variety of roles that today’s pharmacists perform, nor do they accurately reflect the aspirations of many of our colleagues to pursue different and expanded roles.

“If I had to answer the question ‘What is a pharmacist?’ I would say, first of all, someone with the appropriate qualifications in the field. Second, a person who has been duly accredited, certified, or regulated to carry that title in their jurisdiction. Beyond that, the specific job, tasks, and daily activities that a person undertakes are entirely immaterial, as long as they possess the necessary degree, registration, and legal authority to call themselves a pharmacist. Beyond that, pharmacists can engage in a multitude of diverse activities, far too numerous for me to enumerate or describe right now.

How relevant is the word pharmacist?

“Labels or identities, which in the past served as convenient ways to categorize people, no longer adequately encompass the complexity of individuals within those categories. This holds true for various categories, whether they are based on professional designations, national designations, or characteristics like race or sexual orientation. Single labels tend to oversimplify things. The reality is that people are much more multifaceted than a single label can convey.

“So, if we approach it from another angle, I might rephrase your first question as, ‘Do you think we are witnessing a shift in the perception of expertise?'”

It’s a very interesting question. Continue.

“I don’t believe we are witnessing the demise of expertise. What I think we are observing is a profound evolution in our understanding of what expertise entails. Even individuals who have historically considered themselves experts may be holding onto a notion of expertise that is no longer widely embraced in society.

“This disconnect can be psychologically challenging for us, as individuals, to accept because society’s perception of expertise is rapidly evolving.”

It’s fascinating, isn’t it? Do you think people fear losing their perceived ‘expert’ status, especially within the groups you described in your initial response?

“Absolutely.

“Over time, many individuals tie their self-identity closely to their expertise, professional designation, or title. We invest significant time, effort, money, and energy into becoming experts and obtaining titles. As a result, we often expect to enjoy the benefits of these accomplishments for years to come, assuming that we can rest on our laurels. Unfortunately, it’s not as straightforward anymore. The idea of coasting on the laurels of a designation, title, or degree has become increasingly challenging. It’s a slippery slope, and this fear may not only shape personal opinions but also hinder progress.”

Let’s change tack slightly. How do you perceive the role of technology in relation to the topics we’ve discussed?

“I believe that’s a significant aspect. With the proliferation of technology, access to expert-level knowledge has become universal. Almost any well-educated individual can quickly acquire extensive knowledge about pharmaceuticals with minimal effort. Additionally, if someone is personally affected by a medical condition, taking a medication, or experiencing an illness, they now have an incentive to become an expert in that area, given the access to an abundance of information.

“This poses a challenge for healthcare professionals, including pharmacists, who do not possess personal motivation to acquire expertise in various diseases. There is simply no way for an average pharmacist to keep up with all areas of expertise that patients may seek, especially when their own motivation is lacking. This has contributed to a loss of professional status, not only in pharmacy but across healthcare professions.”

I was referencing an article you were involved in back in 2010 regarding pharmacists’ perceptions of their abilities. I’m interested in hearing your description of the current professional culture in pharmacy.

“The article you mentioned was an attempt to explore the broad literature examining pharmacy culture, pharmacist traits, and behaviours, particularly in the context of an evolving scope of practice. We see similar trends in many countries, including Scotland, where we’re at the forefront of these changes.

“What the literature tells us is that several relatively stable traits are commonly exhibited by pharmacists, although not universally. When a majority within a group exhibits certain traits, it starts to shape the culture, and this culture, in turn, influences those who do not share those traits. Some of these identified traits include a strong aversion to taking risks, a low tolerance for ambiguity, and difficulty operating in information-imperfect environments. Another prominent trait is a strong desire to be liked and an inclination to avoid conflict.

“When these traits are prevalent among a significant portion of a profession, they begin to define the normative behaviour within that profession. Those who deviate from these norms may either leave the profession or feel compelled to adopt behaviours that are inconsistent with the established culture, leading to a sense of not belonging.”

Do you think that pharmacists, in general, might be hindering their own progress and potential for growth?

“That’s a very interesting question. The way you framed it presupposes that the ideal path for professional evolution involves a clinical, patient-focused model of practice. I must admit my own bias in favour of this perspective. However, I’m not asserting that it’s definitively right or wrong.

“The interesting aspect is that this perspective leaves limited room for individuals who may not share the same vision. Let me provide a personal example. I graduated and became a pharmacist at a time when pharmacists were not expected to engage extensively with patients or consult with physicians on prescribing decisions. We certainly didn’t administer vaccinations or independently prescribe them. In fact, I never imagined giving someone an injection. To this day, I am not particularly fond of receiving injections, let alone administering them.

“Many individuals are drawn to pharmacy because it historically allowed for a relatively hands-off approach to healthcare. You could possess extensive medication knowledge without the need to take on substantial patient care responsibilities. However, over time, this paradigm has shifted, and well-intentioned efforts by regulators, professional organizations, and educators have expanded pharmacists’ roles significantly.

“Yet, the foundational trait of aversion to direct patient care and discomfort in taking on responsibility in uncertain situations doesn’t change overnight just because someone gains the ability to prescribe. What does change is the ability to openly discuss these reservations. As expectations shift, many pharmacists may outwardly support these changes but find it challenging to fully embrace them in their daily practice. They may not be as enthusiastic about these expanded roles as they are expected to be.

“This poses a significant challenge, as the profession has evolved rapidly, and many practitioners may find themselves struggling to keep pace with these changes or to fully align their practice with new expectations.”

I am fourteen years into my career. I started in a community pharmacy. Dispensing activity dominated my role, I was not an independent prescriber and pharmacists administering vaccinations was rare.

Anyway, I progressed to become an independent prescriber and went down the route you described. Well-meaning advocacy groups have pushed for pharmacists to do more, which leads to an interesting question. Who’s driving it? What’s driving it? Is it all about money? The original call to action around pharmaceutical care by Helper and Strand in 1990 was largely focused on medication safety.

So, do you think pharmacists should focus on what they perceive themselves to be good at or is it time for change? Maybe that’s where our real value lies. As a profession are we being too limited in the expansiveness of our thinking?

‘The philosopher Kenneth Burke once said, “Every way of seeing something is equally a way of not seeing something else.’

We’ve prioritized one way of being a pharmacist, the clinical route while undervaluing many other contributions pharmacists can make. “We need to recognize that there are many ways of being a pharmacist, just as there are many ways of being Canadian. We shouldn’t make one way superior to all others.

“The desire for clinical roles might stem from an inferiority complex some pharmacists have about their professional choice. This complex is reinforced through education, professional socialization, and societal hierarchies.

“Many pharmacists have a fraught psychological relationship with physicians, possibly due to feelings of inferiority. The process of becoming a pharmacist is highly competitive, and we tend to rank professions ruthlessly, despite small differences in intellectual capacity between them.

Have you got a view on how the profession of pharmacy interacts with business?

Pharmacy as a business is often demonized. However, it’s crucial for responsible stewardship of healthcare resources. We shouldn’t devalue this role. Embracing a variety of roles within pharmacy can enrich the profession. Every role contributes to the overall success.

Pharmacists who embrace business can contribute to responsible stewardship of healthcare resources.

What common traits or behaviours have you observed in pharmacists in your research?

“There may be foundational personality differences between individuals who choose medicine and pharmacy careers. Agreeableness and conscientiousness are two personality traits that differ between these groups, which may influence their tolerance for ambiguity and perfectionism.

“Pharmacy students tend to be more conscientious than medical students. When you have differences in agreeableness and conscientiousness intersecting, it creates a fertile ground for variations in tolerance for ambiguity. When you strongly believe in rules, you tend to have a mental model that suggests there’s always a definitive right answer. Conversely, when you possess less of a conscientious orientation, you may not always assume there’s a single correct answer.

“You tend to find greater psychological comfort with what psychologists refer to as ‘least worst alternatives’ rather than insisting on absolute right answers.

“Let’s get into the topic of education shortly, but I would suggest that, from the outset, our personality traits, particularly among pharmacy students who often score higher in conscientiousness and agreeableness compared to their medical counterparts, set the stage for what you termed “procrastinating perfectionism.”

“As students progress through their education, this trait is further reinforced. There’s a substantial body of literature on clinical reasoning, which we could explore more in another interview. However, it’s evident that pharmacy and medical education, especially medical education, diverge from most other health professional education in fostering comfort with ambiguity.

“The question of why we become procrastinating perfectionists is complex and multifaceted. It begins with our personalities, continues through our educational experiences, and is ultimately solidified by the broader culture within our professions and the professionals we interact with.

“Regarding tactics in medical training that improve comfort with ambiguity, there’s a shift in perspective. Instead of meticulously setting up the perfect opportunity, the focus has shifted toward taking more shots. The idea is to keep trying, learning from mistakes, and building forward momentum. It acknowledges that perfection is elusive and that embracing failure as part of the learning process can lead to success.

” In terms of business, you mentioned feeling comfortable with ambiguity and the acceptance of failure. It’s akin to the concept of taking more shots in ice hockey, where repeated attempts lead to success, despite many failures along the way. This mindset aligns with the willingness to embrace uncertainty and learn from it.

“Your comfort with ambiguity in business, combined with your risk-tolerant approach, allows you to explore new ideas and take calculated risks. While you may be risk-averse with finances, your willingness to try new things and seize opportunities demonstrates comfort with ambiguity in the business realm.”

“You’ve encouraged listeners to learn more about themselves and their Big Five personality profiles. Recognizing one’s traits and tendencies can be a valuable step toward self-improvement and achieving personal and professional goals.

To close, what advice would you give to newly qualified pharmacists coming on to the register?

“I would say, don’t limit yourself to a narrow view of what you can do. Understand your interests, be honest in self-appraisal, and pursue a path that allows you to be the pharmacist you want to be, not the one others dictate. Everyone has something important to contribute; unleash your potential to make that contribution.”

References

Rosenthal MM, Austin Z, Tsuyuki RT. Barriers to pharmacy practice change: Is it our nature or nurture? Canadian Pharmacists Journal / Revue des Pharmaciens du Canada. 2016;149(6):317-319. doi:10.1177/1715163516672832