Can your local pharmacist do more than just fill prescriptions? Millions of Canadians struggle to access timely primary care. Could your local pharmacist be part of the solution? And what does the data really say about the impact of expanded pharmacy services? #ICESOntario Dr. Mina Tadrous joins In Our VoICES to unpack the numbers, the debates, and the future of healthcare delivery in Ontario. We're diving deep into how pharmacists are stepping up to fill critical gaps in our system. Listen now to understand this major shift and how it might affect you and your health.
A note that this episode was recorded during the Ontario provincial election. We also make mention of a few acronyms:
UTI: Urinary tract infection
PPIs: Proton pump inhibitors are a class of medications that reduce stomach acid.
ODPRN: Ontario Drug Policy Research Network
Inspire-PHC: Inspire – Primary Health Care supports Ontario researchers with all aspects of their projects related to primary care.
Our Guest:
Mina is an assistant professor at the Leslie Dan Faculty of Pharmacy at the University of Toronto and the Tier 2 Canada Research Chair in Pharmaceutical Policy and Real-world Evidence. He is also co-director of Pharmaceutical Policy and Pharmacy Practice at the Ontario Drug Policy Research Network (ODPRN) and ICES adjunct scientist. Mina leads research focused on evaluating drug policies and post-marketing surveillance of medications. He works closely with policymakers and uses large data sets to answer questions about real-world safety and effectiveness and improving the optimal use of medications.
Check out Mina’s podcast:
https://www.pharmacy.utoronto.ca/about/im-pharmacy-podcast-season-four
Read the Research:
Applied Health Research Question (AHRQ) Project (in progress): Evaluating pharmacist scope of practice expansion
Misty Pratt
At a time when millions of Canadians do not have regular access to a family doctor, policy makers are turning to pharmacists to help ease the burden on the health care system. Once the go to for prescriptions and over the counter medications, pharmacists are now part of front line patient care. In Ontario, they can assess and treat over a dozen minor ailments, including issues like pink eye, urinary tract infections and cold sores. But this change has not been welcomed by everyone. Pharmacists maintain these changes are overdue and that they are an underutilized resource who can leverage trusted relationships with patients to improve access to timely care and avoid visits to overwhelmed family doctors and emergency rooms. Some doctors, however, feel this expanded scope poses real risks to patient safety and experience of care. But what does the evidence say? Today? We're breaking it all down with Dr. Mina Tadrous, an ICES scientist and pharmacist whose research has helped transform drug policies in Ontario and across Canada.
Dr. Mina Tadrous
The data shows like over 1.1 million Ontarians have already used this service. This is one of the biggest healthcare shifts, like we put out all these programs and things, and maybe we get to like, 100,000 people, and we're excited, but this is 1.1 million people. It's big. This is a big shift.
Misty Pratt
Welcome to In Our VoICES, a podcast that takes you beyond the data to meet the people and hear the stories that help shape health and healthcare for all of us. I'm your host, Misty Pratt, and I'm one of the people behind the data who make the difference at ICES, a health research, data and analytics institute based in Ontario, Canada. ICES staff, scientists and partners are on a mission to make health care better and people healthier. In this podcast, we share our stories in our voices. A note that the opinions expressed in this podcast don't necessarily reflect those of ICES. Dr. Mina Tadrous, welcome to In Our VoICES!
Dr. Mina Tadrous
Thanks for having me.
Misty Pratt
So take us back a bit and tell us what was behind the change in pharmacist scope of practice in Ontario.
Misty Pratt
Well, let me take you back a little bit further to start a little bit. So here I am in pharmacy school, going to all of these pharmacy conferences, and all I hear about is this thing called pharmaceutical care. And I'm sitting in the back because that's the kind of guy I am, and someone next to me, a much older kind of practitioner, leans over, and he's like, "I've been hearing this for 30 years. We're never going to get advanced practice. It's never going to happen." And I practiced for 10 years after that, and I started to believe it, that it would never kind of happen. And we knew within pharmacy that there was a potential to expand the scope to support the healthcare system more than we were doing. We had people who were trained with a doctor of pharmacy, they had very advanced skills, and yet we were under utilizing them. And what happened, I think, was that the system finally stretched to a point that they were open to having other conversations, outside of what the normal conversations were for the healthcare system. So in about 2018 they started exploring what that would look like in Ontario. Now I have to say a big asterisk here, Ontario's late to the party in Canada, but Canada is ahead of the rest of the world in pharmacy practice. So it's kind of an interesting dynamic, like we're very excited about it in Ontario, but Alberta has a much further scope, but has been doing this for a very long time. So Ontario finally said, okay, let's explore what this looks like. And they brought together a committee made up of physicians, pharmacists, healthcare system partners, and we went through the evidence, and we came up with what the initial recommendations would be to the Ministry through the College of Pharmacy to propose what these initial expanded scopes were, they sat on it - fast forward a few years, went through a pandemic. And then I think, if everyone remembers coming out of the pandemic, I think that pressure on the healthcare system, the ED spaces were really full. And actually it was an ICES study that we did that really put the numbers for the Ministry in focus, where we took the minor ailments we'd proposed, we looked at the number of people that went to the emergency rooms for those very things, and the numbers were staggering. It was obvious that people couldn't get to primary care when they needed to, especially in like urgent things, and they were filling up the emergency rooms with very minor things. And so I think it was a real perfect storm. It was a stretched healthcare system. The evidence was ready and the reports were ready, and then I think coming out of the pandemic was just the opportunity to think through this and and think outside of the box a little bit.
Misty Pratt
And tell me more about the minor ailments then, because it's called minor ailments program, and people might not understand what that means.
Dr. Mina Tadrous
Absolutely and I think that's actually what our research has been uncovering, is that one of the uncovering, is that one of the problems is that that naming is really not great. And within the pharmacy community, and, you know, our healthcare partners and whatever, everyone's like, what is a minor ailment, but the official definition is it's something that is self limiting and does not require a diagnosis, because I think one asterisk that people need to recognize is that within the law of Ontario, pharmacists cannot diagnose. That's not within our scope of practice. And so there are things that are recurring, that are self-diagnosed, that a patient can present, and you can go through an algorithm and figure out if they have it or not. The most common one is recurrent UTIs. And so that makes up in our data that we've been measuring about who's been using it, more than half of the delivery of the service is actually that. It's other things like dermatitis, conjunctivitis, runny nose, heartburn, like very typical things that people were going to the pharmacy anyway. I don't know how many times I walk into that aisle as a pharmacist and someone's like, "You know, I got congestion. I got what do I? What do I? You know, these boxes don't make any sense to me." So it's an expansion of that, but now you have the opportunity to prescribe, because there were some times where I wanted to give something or I would say, "Okay, now go to your family doctor. The thing over the counter is not going to work for you'" And then that would just be me putting more pressure on the healthcare system and leading somebody there, when easily it could have been something that I could have prescribed. UTIs is a really great example, and it's why they're most utilized. Women know when they're having a recurring UTI, and so sometimes, a lot of times, the patient would have a prescription sitting on my system in the pharmacy that just says, "Fill when patient logs." So it's five refills, and the patient comes in and says, "You know, I need this." And so if that's what's happening, then why isn't the pharmacist able to also kind of support that process, rather than, "Oh, you ran out of your refills. Let's send you back to your doctor. It's Friday night, okay? The clinic's closed. Go to a walk in or, you know, or go to the emergency room." And that's what was happening. And so I think, you know, back to your question, like, minor ailments are things that are kind of self limiting and can be easily treatable, and that's the scope that we've expanded allows pharmacists to do. So there's currently in Ontario 19 minor ailments that are approved, and there's a current extension of that that's being kind of reviewed, and has some public discourse happening.
Misty Pratt
And we know there are two quite different views on this expanded scope, as I mentioned in the introduction. So the Ontario Medical Association has stated their opposition. And some doctors have expressed that this change could pose a risk to patient safety and the patient experience. How do you respond to that?
Dr. Mina Tadrous
You know, just because this went through doesn't mean that it's like written in stone and we can't change it or modify it. And that's me as a researcher, and why we use ICES data to try to study this is like, let's monitor it. Let's see how we can make it better. And I think that's an important process. The ailments that were picked are things that, generally, people were coming into the pharmacy a lot for anyway. So the idea that there's this massive risk, and we're going to start seeing a flooding of the emergency room because of misdiagnosis and things like that, I think in the last you know, we've had this now up to, I think it's, I think it's been almost two years now, and there hasn't been a massive flag in that way. I think there was concerns about missing red flags. You know, most pharmacists are doing this by following an algorithm, and they're as concerned about anybody else in the risk. And if there is red flags, I think they're referring people out. The data is showing us that not every time a minor element happens is there a prescription. Given it's about eight to nine out of 10 times, but there are times where the pharmacist says a prescription is not appropriate. There was a lot of kind of interesting questions raised about conflicts of interest, and I think one thing to remember is that these things are, one, easily audible. Two, they get paid even if they don't prescribe. So that's the nice thing about the Ontario policy, is that I think a lot of people don't realize that the pharmacist, if they do the assessment, will still get paid. And most pharmacists don't own the pharmacy, so some do, but many of them are just employees, so they don't get paid any extra if they prescribe or not. They want to make sure that that patient's getting the right treatment at the right time. The last thing I just want to highlight to people is that pharmacy has a culture of being rule followers. We actually are worried about the opposite problem, and we did a study during the pandemic where we're using ICES data again, where the federal government had expanded or liberalized the ability for pharmacists to extend narcotic prescriptions to ensure that patients had a continuity. And so the data from ICES helped support the CDSA exemption, is what we call it. And everyone was worried pharmacists were going to start study, you know, like same idea, like that same narrative, like they're going to flood this, whatever. But actually, the data showed that they were likely under utilizing it, because they like to follow the rules. And so with minor ailments, the problem, we think, is that they're not well supported to actually, not all pharmacists are actually using this all the time and reaching their full scope. So we're actually a little bit more afraid of the other problem, which is that a patient walks in, this is a service they can easily deliver. It's well established. They have the tools at their fingertips, and they're just not doing it.
Misty Pratt
Okay? And is that because of anxiety or worry about, you know, is this the right thing or?
Dr. Mina Tadrous
Well, what we were finding in our early qualitative work that we've been doing is that there's a few buckets of reasons. The first part is that they don't feel well supported. So that's why there's been a rush of development of tools and really great startups that are coming out. Been producing a lot of things that can help support the marketplace. The second is, they're super busy. So some pharmacies you walk into, they're maybe doing, you know, 80 to 100 prescriptions a day. I've worked in pharmacies that do three to 400 prescriptions in a single day. They're understaffed, just like everywhere else in the healthcare system, and their priority is making sure the patients get the medication. So this feels like an add on, because they need to get those drugs out into that patient. That's their priority. And they make sure they check it, they make sure it's billed, they make sure everything's done correctly. So I think they're just sort of stretched. The third thing, and this goes back to your first comment, is like sometimes they have relationships with doctors in the area, and they may not feel that that relationship or the balance of what's needed by their patients is supported by offering this service. And I think that's where some of our work is going, like, how can we have those conversations where we align all the services with what the system needs? Because I think that's the biggest concern, is that this was rolled out, and the data shows like over 1.1 million Ontarians have already used this service. This is one of the biggest healthcare shifts, like we put out all these programs and things, and maybe we get to, like, 100,000 people, and we're excited or but this is 1.1 million people. It's big. This is a big shift, and yet, just like everything else, it's siloed. There's no integration into primary care. We didn't think about, what can we link this in? Can we reach out to the family health team down the street and say, "Hey, we can offer this service? How can we better support that?" And I think that, for me, is sort of the bigger concern is that we're squandering a really great opportunity to build an extra capacity that should be better integrated, and yet, we're doing what we always do in healthcare, we just add it on and it runs in a parallel, siloed process.
Misty Pratt
We sometimes hear pharmacists are not doctors, which is true, but clearly there is a level of expertise there that's important. So what do you say when people ask you about that expertise?
Dr. Mina Tadrous
You know, the pharmacy education piece has been seeing a massive expansion and shift. Over the last 30 to 40 years, we've actually had the opposite problem, which is that we over trained our pharmacists, and the realities in the healthcare system weren't matching the skills we're building in them. If you compare the number of hours that pharmacists take doing therapeutics and thinking about drugs and how to test them and how they're developed, versus other healthcare professionals, it's very obvious who the expert on drugs is in the room, right? And how much time they spend thinking about that. So I think the problem we had was actually the opposite. We over trained them, and they would go out into the workforce and wouldn't utilize all the things we trained to them. So we've been teaching minor ailments. We've been teaching prescribing, monitoring, all the things we've talked about on this podcast. We've talked about we've been trying. Been training them, the disservice that we felt really bad about is that we would then send them out into the system, and if they weren't working in hospitals and they were working in the community, all the things we taught them, they weren't using hospital's a very different case where we've seen advanced clinical pharmacists for a very long time, but in the community, it wasn't happening. And so I think we're finally now seeing the regulations and the scope of practice catch up with the education, and for us as educators, it's very exciting.
Misty Pratt
And going back to your previous point about conflict of interest, so pharmacists are not getting paid for this, or they get paid the same regardless. How do you answer the worries about corporate pharmacies about you know that they're lobbying for this because they make a lot more money if they do these if they do this program.
Dr. Mina Tadrous
I think what we call business pressures is a concern. I will make two notes. One, business pressures exist everywhere. All right and so you know most other healthcare partners and systems, many of them are incorporated. Many of them are also worried about how much they make. And so I'm not negating this. I think it's one of those things, like, we face it and we say, like, this is what's happening, and we have monitoring, we have rules, and we ensure that that is we don't tuck it under the rug, and we have people like ourselves studying this to make sure that something strange is not happening and that the quality is there of these services. And that goes back to why a place that's independent, like ICES and people like me studying this is so important, and why the Ministry cares that we continue to evaluate it to improve it. With that being said, I think when you do some math on how much money is actually made, the reason that the corporates want this is not because they're going to make a flooding of money. Most of the drugs that are being dispensed are generic. They're making sense, if not a couple of dollars. They actually make more on the services themselves, so they don't really need to dispense it all out. They're not prescribing expensive drugs here. These are PPIs, hydrocortisone creams, really cheap antibiotics. So the flood of money is not from these extra prescriptions, right? Like this is not that's not where it is. Where it is. Is that their vision is that they want to create community hubs and offer healthcare services in these hubs, which brings people in the door, and all of a sudden you have this place where, and this is the same vision that was pitched by Walgreens in the US about 20 years ago. If I create these clinics that have services. Yeah, and this is the same reason why pharmacies bring a doctor and they give them really cheap rent to be next doors, because they want them to come in. They know they're going to fill their prescriptions there. So it's more of like the holistic view that they're trying to get, and that happens to make them money, but it's also filling a void where no one can get access to anything past five o'clock. You can't go on the weekend, and so they're thinking, if I could do point of care testing, I can check your blood pressure, I can prescribe you some medications if you need it. And this is a place that we have, they're going to fill that void there. Now, should we make sure that they're not the quality doesn't drop because they're rushing to make money, absolutely but we also need to be taking a hard look at why is there a need for this, and is there other ways that we can be using this? Using this? It goes back to my previous point of, how can we better integrate this, regardless of what the setting is, ensure the quality, but also integrate this in a way that meets patients needs.
Misty Pratt
On that point of patients needs, so I don't know if you've done qualitative work on this, but what are you hearing from patients about the experience? Because I have heard a few things here and there of you know, they're at the counter and there's a long line of people waiting for prescriptions, and they're trying to talk about this sort of a slightly embarrassing thing in front of everybody. So is there, is there feedback there from patients?
Dr. Mina Tadrous
Yeah, and we've given that back to everyone. So in the first year, we did qualitative studies where we talked to pharmacists, physicians and patients. So the first thing we heard from patients is they love this. They're really happy. It was very positive. They generally are excited. They had three major concerns. The first was what you just cited, like, no one wants to be talking about their strange rash, or someone is next door in the middle of the hallway. And so some pharmacies have private rooms, but not all do. And so one recommendation we've had is, like, if you want to offer the service, like, you got to be meeting some privacy requirements here. Like, we got to fix this up. This is unprofessional. Some of these private rooms were popping up before because pharmacists have already been vaccinating. You know, sometimes we have to counsel on very concerning issues. Like, it's not nice to be you know, these are not the only times we've been talking about sensitive issues with any patient. And so many of the pharmacies I like to work at often have a side room or a place that we can go to have those conversations. The second thing is that first question you ask, like, what is a minor ailment? So I think you saw these commercials come out, like, talk to your pharmacist. Talk to your pharmacist. Maybe their friend told them, Hey, you don't gotta go to the emergency room. You could just go to the pharmacy. They go in, and then the pharmacist has to tell them, "No, this is not what we do. Like, this is not within the 19." And then they say, "Well, I thought you could prescribe." And so I think that is difficult, because even within pharmacists, we're sometimes talking about, like, is this within the scope physicians are like, can you prescribe for that or not? What counts and what doesn't? And so I think there's frustration from patients where they thought they had this pressure valve that they can go to now and then the service can actually be offered. And so the complexity of that was one of the bigger complaints about, like, what's actually happening. And then the third thing on that same note is that even though there were a few advertisements, people felt like the only way they found out about it is because they happen to have a cousin that was a pharmacist, or somebody is a friend, or whatever. And so they were, I think they were saying, like, how do we get more people to do that? And then the last footnote is what we were talking about before, which is, like, not every pharmacy is offering it.
Misty Pratt
Oh, okay, so it's not all of them.
Dr. Mina Tadrous
So every pharmacist can do it. But you might walk in and they say, Nah, we don't, we don't do that, right? And so it seems like there's some different experiences where it's not a full view. And this is the same problem in other provinces, where you know not every pharmacy you walk into offers this service. And so how do we navigate that? Do we do we start putting up signs that say what we do offer, and some pharmacies have started doing that, but that means you have an inconsistent experience of what you get out of the pharmacy. And I can imagine that's frustrating, because you generally don't go to a doctor, you know, I think you know what you're going to expect to get out of it, but now with pharmacy, you go in and you you might not get the service that you think you're going to get. And that's, that's a real issue, I think, when thinking about consistency. So I think what we're thinking about is those pharmacists that don't deliver it. How can we support them to be able to deliver it? I don't think everyone's going to do a high volume, but they should feel confident to be able to deliver some things to the needs of their patients.
Misty Pratt
On the other side, this has been championed as a positive solution for patients. As you've already told us, the many positive outcomes from this. Lot of people don't have access to a family doctor. They don't have timely access, so they can't get an appointment for, say, two, three weeks. So this could really help our system. It could help overwhelmed emergency departments and overwhelmed family doctors. But what does the evidence say? Have you started to track and look at the data to say, Yes, this is definitely already helping.
Dr. Mina Tadrous
So we are, and we're trying. You know, I think from day one, the Ministry asked us at the ODPRN, which is a team that uses ICES data for a long time to monitor what's actually happening. So the first thing we wanted to do is see who's using it, which ones are the most common ones, to better understand which patient populations are being left behind. We did some work with Inspire-PHC, which is a great group that also uses ICES data that looks at primary care, and they better understand primary care to better understand how people who are using it are linked to the healthcare system. Because, you know, the initial expectation was that this would help fill the void of those that five to 10% that don't have a primary care physician. And then the next step that we started to, you know, work on is, well, are we seeing a drop in emergency room visits? So the early data kind of shows that in some cases, we're seeing sort of a flat lining, or some some initial drops. It's not consistent. I think this is one of those problems where, like in most things in healthcare, there was so much pressure on the system that, if you take a little pressure, that void just fills. So I think we were excited to see a flat lining that the rates of growth we looked at UTI specifically, wasn't continuing to fly up, but you don't see like a, you know, a displacement, and suddenly there's like extra space in the healthcare system. But you do see on those specific things, a drop in those spaces. There's data that's come out of Nova Scotia that showed that for the specific ailments that they've done, five to 10% drops in emergency room visits. And so I think we're expecting, as this picks up around Ontario, as we continue to monitor this, we'll pick up a little bit. My gut tells me we're probably going to see a flat lining, which, in all intents and purpose, is a good thing, like we we kept just adding on more and more and more, but that that's an important part. The other part we want to sort of see is, how does this integrate into the system and who's getting access to it. So unfortunately, what the early data kind of shows is that, like most new things in healthcare, people of affluence get first access. So we didn't see an equal distribution across marginalized kind of communities. We saw it used more in well off, higher socioeconomic neighborhoods. We didn't see a massive uptake in more small communities, in rural areas where we wanted to see the uptake. But I think we're gonna slowly see that that trend is kind of catching up with the rest of the province. That was the same thing we saw with virtual care in the very beginning of the pandemic as well. Like it catches up in a big way. And then the other part that's kind of an interesting piece, is that we didn't see that the void was filled for that five to 10% of people who weren't attached, but what we did see is that there were people using it who were unattached, which I think is a very good news story, which means that these people are now getting some health care that's not just showing up at the emergency rooms. So I think there's a lot more questions to be asked, and we continue to monitor this, but generally, in the beginning, we are seeing some evidence that it is taking a little bit of pressure off the healthcare system, and it is giving people another choice, because it's obviously really popular and being used quite a bit.
Misty Pratt
Other than emergency room. Is there any other patient safety data that you can track to say that you know this visit led to something else that an adverse event of some kind?
Dr. Mina Tadrous
So I think we're now just trying to figure out how to link the prescriptions to see if they got a drug or not. And I think naturally the next question we ask is like, is this leading to them following up with their family doctor? Is this leading to them getting an inappropriate prescription of some sort? We are working with public health Ontario and some of the colleagues there in infectious disease to look at what happened to the antibiotic prescriptions, because you can imagine, for them thinking about inappropriate antibiotics. Now you have a new class of prescribers, and what the early results in working with them has shown is that, no, we didn't see a surge of people using naughty antibiotics that we tell them not to. We see a rather flat line, and we see a bigger uptake of the first line UTI antibiotics, which you expect, because now you have more people getting treated, but it seems like the appropriateness has stayed about the same, which is not a good thing and not a bad thing. It means that we can also continue to educate this new class of prescribers to improve their prescribing as well.
Misty Pratt
And for the provinces that have been doing this for a lot longer, like, say, Alberta, is there more data out there that you can kind of point to, to say, you mentioned Nova Scotia, but I wonder if there was any other provinces.
Dr. Mina Tadrous
Yeah, Nova Scotia is a little new to the party as well. Like I think they rolled theirs out. BC rolled theirs out around the same time as us, but Alberta's kind of had the more expanded scope. But Alberta's model is a little different in the sense that they're not as prescriptive, and you have to do extra training, and they become these sort of more advanced pharmacists, in some ways, but their scope is way beyond what it's not 19 things. It's like they could do a lot of things they could prescribe. And there's some really great evidence out of it. There's people who have been doing research to show that when pharmacists are involved in helping control people's blood pressure, or they link in with primary care, you get better control, you get better outcomes. And so you've sort of seen this piece mailing of things, and you know, I think it's a little frustrating, because it seems logical. I think taking a step back, pharmacists are the number one most interacted with healthcare provider. The data shows that the average Canadian goes to their pharmacy 12 to 14 times a year. They go to their family doctor or any doctor two to three times a year. So that's like five times more interactions. So those are all missed opportunities. If we want to be able to interact with them, we want to give better care. We want to monitor and better patient education. And so I think this has been a long time coming to think about like how we can integrate more. And I think for me, what I if people are listening, the bigger urge that I want people to have is that, how can we integrate this better? How can we actually use this to our advantage, rather than trying to fight it? Let's say, what is the best way to optimize this new scope that it makes sense. How do we get the most bang for our buck out of the system to ensure that we integrate with, you know, primary care that we communicate between those clinics. We may, you know, we're gonna have more point of care testing coming out of pharmacies. We don't have a very good urgent care system in the province. This isn't a pressure valve for us. So this is a unique opportunity. I think this is the moment to be creative. This is the moment to, like, work together and kind of like try to integrate the system. And I think as we change the primary care system in the province, leaving pharmacy behind is probably like a bad decision when this is already happening.
Misty Pratt
So it sounds like to bring these two sides together, these opposing sides, I guess you could call them, we need to focus on the integration, on the creative, you know, the creative aspect of this, may be a solution.
Dr. Mina Tadrous
For my physician colleagues that may be on the fence about all this, what I would say is think about how this could be advantageous to you. So, you know, I tell people these stories all the time, where I used to work at certain pharmacies, where we shared a back room between us and the physician clinic, and that space would allow us to just interact with each other and do certain things that you know the physician didn't know was possible. For example, a new Health Canada warning comes out about a certain drug, and there's interactions. I would go through my list and print off all the patients, make recommendations for them and make their life a little bit easier. And then they would say to me, "Okay, well, if you see all these patients, can you flag it? And then we can do this, and we can switch them off this drug." And you find out that that doctor now has 200 patients, that's 200 more visits they were gonna get. Another example is a drugs on recall. A shortage happens all the time. They're like, "How am I gonna deal with this?" Like in 2017 Valsartan, one of the most commonly used blood pressure medications, massive shortage. 200,000 Canadians switching in one single month. That is a pain in the you know what right? And so if you don't lean into your pharmacy colleagues to try to help you navigate that that's all going to end up on your desk right? For vaccinations, these were people that you can like refer to your pharmacies for small visits. If your rooms are full, like, how do you get them, be like, you know what, and some family health teams have started doing this. You know, we have a good relationship with the pharmacy down the street. This seems like a common issue. You should just go there and get this done with.
Misty Pratt
Yeah, it takes a lot of pressure off them - it sounds like.
Dr. Mina Tadrous
Right but this comes down to not data. This doesn't come down to, like, some fancy policy. This comes down to, I think, having a phone call or a coffee with the pharmacy down the street and just good old networking between people, which we don't do that much in healthcare, and say, what can you offer me? How can I make your life easier? And I think that'll change the conversation, rather than being adversarial about it. And I think across this province, you see lots of doctors who will say, "Yeah, I know that pharmacy down the street, and they've saved my butt a lot, and I have a good relationship with them." And I think those are the things where you see like, these sort of like centers of excellence, and you see these good moments, and I'd like to see that spread and use this advanced scope to be a little bit stronger for everybody else. And I think in the end of the day, that's going to really benefit patients in a massive way.
Misty Pratt
So better communication is usually what.
Dr. Mina Tadrous
That's in a very simple way. You know, I know we're supposed to talk about data, but like, although I think the data, it's both. I think the data can support it to tell us, you know, what we're thinking about is like, can we tell people where they should be going? Can we create an understanding of communities? Can we help pharmacists with data to know how they're doing? Like an audit and feedback for pharmacists as well? There's a lot that we can be doing to evaluate and better understand how to make this process better, but I don't think we can solve for just communication between people and just, you know, picking up that phone or having that coffee with the pharmacy and the physician down the street and seeing how we can help each other to help, you know, with the caring of Ontario's patients.
Misty Pratt
Do you see pharmacies, range of services, continuing to expand in the future, then? And what are your hopes?
Dr. Mina Tadrous
So, you know, we're in the middle of an election, right? You know, I think that we know that the current government that's up for re election had a consultation that was going on that was going to further expand beyond minor ailments to allow some assessments of less complex issues, but they're a little bit a step above the minor elements and are likely going to require extra training. But I think what you're seeing is that expansion is a nod towards pharmacy, saying that the first 19 worked. This worked for the system. It's been positive. I think the public has achieved it. I think what we're going to start seeing is more point of care testing. I think we need to see pharmacists able to help patients navigate the healthcare system better. And I think the next phase is also as primary care is re-imagined and we work on tools that help patients navigate like portals to enter in. What you're going to start seeing is that pharmacy is going to be included as one of those pressure valves. So if you call the number, or you go online and you say, "I have this issue." If you fit into that algorithm, they may refer you to your pharmacy. And I think that's what we're going to start seeing is as that list expands. More things are going to be referred there, especially after hours, weekends, things like that, where we know other clinics are not open or working, and I do see kind of like a broader expansion in that space. I also think that there's an opportunity here to start more standardizing these collaborative agreements. So if you're a physician and there's a pharmacist down the street that you feel comfortable with, you can start saying, "Okay, you know, I have all these patients that have diabetes. Can you monitor them? Can you review their medications? Flag things for me. And if they fall within this bucket, like they're A1C's at a level, can you just shift their drugs?" These are things that have been happening around the world for 30 years. I think we're going to start seeing more of that, where the pharmacist can be better involved in monitoring of chronic disease, and that'll also take a lot of pressure off the system as well.
Misty Pratt
Are you also looking at better outreach to the communities that you know right now are not accessing the pharmacy care that they need?
Dr. Mina Tadrous
I think one thing we're going to start thinking about that's been really well highlighted in the US is these, like pharmacy deserts, of where there aren't pharmacies, and how we could get people there. This is always going to be, you know, Ontario's a massive province when you think about size wise, and I think in the rural areas, it's going to be a major issue. And how do we ensure that there's proper access there, and how do we ensure that those pharmacies are supported to be able to serve those communities? But I think we are going to start having a conversation about, how can we support the pharmacists that are not comfortable to do this? How can we let them know how they're doing? You know, the other problem is, just like family doctors, pharmacists, are super siloed, so they don't learn and talk to each other in any way. So I think using data and tools to try to tell them how they're doing is going to be super important so that they can find room for improvement. They can be supported to expand their scope, to keep up to date, with the most recent evidence, and I think working towards that space. So I do think there's lots and lots of work to be done in this space, as this is something new, and, yeah, you are going to see further expansion, I believe, as more success happens. But with that being said, I think there's also a chance here to tweak what we have to optimize it. We think we know how to roll this out, but Ontario's unique, just like every other place, and I think we need to be very candid about how to optimize how the pharmacy services fit into the context of Ontario's healthcare system.
Misty Pratt
And how to communicate that to the patients.
Dr. Mina Tadrous
And yeah, and how to get he public on board with that, absolutely.
Misty Pratt
Thank you so much for being here, Dr. Tadrous, I learned so much. It was really informative.
Dr. Mina Tadrous
Thanks for having me. Thanks for covering this topic. It's always great to talk about pharmacy. I think for a long time, we've kind of taken it for granted we are one of the older professions, but I think we're reimagining what being a pharmacist in this province looks like, and it's it's a really exciting phase for us as pharmacists. We're really excited to see this expanded scope and to be able to pitch in a little bit more into the healthcare system and help our patients more.
Misty Pratt
Very exciting. Thank you.
Dr. Mina Tadrous
Thanks for having me.
Misty Pratt
To hear more from Dr Tadrous. You can listen to him as host of The I'm Pharmacy Podcast from the Leslie Dan Faculty of Pharmacy at the University of Toronto. From drug discovery to de-prescribing, they are exploring and pushing the limits of the profession and the science, resulting in better medications, a better health system and better health. Thanks for joining me for this episode of in our voices. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you've heard on In Our VoICES, please email us at communication@ices.on.ca and we'll be sure to get back to you. We might even share your feedback on a future episode. I'm Misty Pratt and wishing you strong data and good health.