Professional Judgment

Store manager/district manager/grocery manager/pharmacy supervisor:  We have received a complaint from Mr/Mrs/Ms Jones saying you will not fill his/her Xanax.  What is the problem?

You: It is too early.

Manager/supervisor:  How early is it?  No, that does not matter.  Jones wants the Xanax and you are not taking care of your customers.

You:  I am taking care of my customers.  One way to do so is to dispense their medications in a timely manner.

Manager/supervisor:  The only way to provide customer service is to make the customer happy.  Jones is not happy.  Thus, you are providing poor customer service.  Fill the prescription.

You:  No, it is too early.

Manager/supervisor:  How can it be early if the customer is requesting it?

You: (Heavy sigh)  Look, this may be a HIPAA violation but the fact is that Jones has a history of misuse and abuse of drugs.

Manager/supervisor:  The only fact I am interested in is that we have an unhappy customer.

You:  My professional judgment tells me that Jones needs to wait and Jones is going to wait until the medication is due.

 

I get regular e-mails and phone calls about this conversation.  It is taking place much more often than a few years ago, by my reckoning.  Pharmacists, already under pressure and stress from added duties and cutbacks in hour and tech help, are now having their professional decisions questioned.  Often, those people questioning these decisions are superiors with no professional experience, education or license.

The reason more such conversations are occurring is that premise I repeat over and over: with the pharmacist shortage over, employers feel free to heap on more responsibilities and push company and corporate attitudes over the professional judgment of the employee pharmacist.  The pharmacist then faces the dilemma of acting on her professional judgment and risking future employment or giving in, compromising her status as a professional.  With a mortgage, school debt, maybe even a spouse and children, the pressure exerted these days often forces the lesser of the two choices.

Professional judgment must be exercised as it is in the best interests of the patient. Further, it is an act that is the culmination of years of education, honing skills, and gathering experience in the professional environment.

Let us look at professional judgment (PJ).

First, in order to have PJ, we must be professionals, so let us define that.  A profession is an occupational group that requires special, usually advanced, education, skill, and knowledge, followed by licensure and possibly oversight by one or more government administrative agencies.  A profession usually reserves to itself authority to judge the quality of its own work, though the people it serves also has that right.

So, what is PJ?  It is a decision making power allowed by law based on your education, skills and experience to either perform or not perform an act.

Factors to consider in the exercise of PJ:

  1. Is the action in the best interest of the patient?
    1. take time for & consider the needs of the patient
    2. respect the views of others—both professionals and patients
    3. be empathic and non-judgmental
    4. act fairly
  2. Are you exercising proper expertise and knowledge
    1. use info at hand
    2. gather additional info needed—use appropriate communication skills
    3. observe/listen/assess the benefits/risks
  3. Is your decision one that your peers would consider reasonable given the circumstances
  4. Document what you did and why—if it is not documented, it did not occur

 

Results of proper use of PJ:

  1. Right patient getting the right drug/dose/directions/duration
  2. Promote the health and safety of the patient/public
  3. Protect the patient/public from unreasonable dangers
  4. Upholds the dignity and honor of the profession

 

The proper use of PJ can and should prevail over almost any dissenting opinion.  Further, it will almost always protect not only the patient but also the pharmacist.

 

Should you sell this person syringes?  Should you sell this person OTC codeine cough syrup?  Should you fill this prescription or contact the prescriber first?  Would filling this prescription today be the correct time to do so?  When I am alone in the pharmacy, can I shut part of the gates?

 

These questions belong in the purview of the pharmacist, and no one else in the employment environment, unless the pharmacist seeks input in order to make the best decision.

 

So what should you do when your PJ is attacked by superior members of your workplace?  Contact the Board.  Right now, Boards of Pharmacy are protecting PJ like mama grizzlies protect their cubs.  State your case, set out the facts and explain how and why your PJ led you to make your decision in the manner you did.  In most states, your manager/supervisor will be getting a phone call within a few hours and the matter will be settled.  Indeed, most employers do not like attracting the Board’s attention and will back off upon hearing of your intent to contact it.

 

If you have doubts about a decision, have a network of pharmacists you know and trust set up to contact and go over the scenario and how you want to handle it.  Call them and discuss an issue calling for PJ and express your opinion and doubts, if any.  Listen to their input and be open to their opinions.  When they support you, go with your PJ.  When they do not, form a concensus and act on that.

 

I do not have a great answer to the dilemma of protecting your job.  The shortage is over and currently employers hold the better cards.  But we do have to deal with protecting the patients.  We do have to deal with protecting our rights as pharmacists, and we have already surrendered too many.  We do have to deal with living with ourselves if we let bosses (often non-pharmacists, non-professionals) dictate PJ to us.

 

The law is not exact upon the subject, but leaves it open to a good man’s judgment.

Hugh Grotius, 1583-1645

 

Let us be those good men.

 

(Definitions of “professional” and “PJ” constructed by Peter P Cohron)

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