Response

Response

Tsuyuki and colleagues have expressed some pointed criticism of our recent commentary. In response, we hope that our article was not construed as criticism against the work of previous pharmacy practice research projects or researchers. On the contrary, we have incredible respect for the work of Dr. Tsuyuki and others who are engaged in practice research. As a point of clarification, we are not arguing to shift the overall focus of pharmacy practice research in Canada. Indeed, we are also pursuing novel practice strategies that push the boundaries of what is achievable in today's professional environment.

However, our major concern is that available practice research studies have not provided enough information about how today's typical community pharmacists can contribute to patient care. Tsuyuki et al. suggest that previous research “may be limited by the relatively low proportion of pharmacists that participate.” Our view is somewhat more realistic — previous protocols cannot be carried out in typical pharmacy practice as it exists today. The evidence supporting this statement is obvious, as the majority of “early adopters” participating in these studies cannot carry out their assigned tasks. Should we be surprised? Many pharmacists cannot predict if they will eat lunch on any given day, much less schedule a visit with patients for disease management.

Regardless, Tsuyuki et al. suggest that environment, corporate cultures, workflow, and other barriers are just excuses for the status quo. Ultimately, practising pharmacists must be to blame because all they have to do is spend more time with patients providing good pharmaceutical care. The people waiting for prescriptions can wait, lunch can wait, and certainly any community service or family activities can wait while you dedicate your life to your patients. It would seem that Tsuyuki et al. are only concerned about what pharmacists should do rather than the more difficult questions such as when, where, and how.

Although we did not present any of our specific ideas in the editorial, Tsuyuki et al. have predetermined that our paradigm represents “watered-down half measures” and “suboptimal care” that will “likely have no impact on patient outcomes.” They even suggest that our efforts may damage our profession and we should conform to “become part of the solution.” Perhaps they need to be reminded that the “solution” has not yet been found. Patient outcomes have not been influenced to any significant degree in community pharmacy risk reduction studies, even in the most highly regarded publications.

As such, there is a great need to explore new ideas as well as refine traditional paradigms. However, Tsuyuki et al. argue against the value of investigating small changes on the premise that “low power” and “type 2 errors” will not “help our cause.” We believe our “cause” is to facilitate better patient outcomes by improving on what we do. We are in the midst of an epidemic of nonadherence that needs our immediate attention. The reference to this critical issue as a “moot” point is puzzling, to say the least.

Regardless, we do appreciate the offer to become part of their solution, but we will continue to search for a solution that works. Hopefully, others will appreciate that researching novel strategies may provide more information about what the actual solution might be. However, traditional pharmacy practice research has been conducted “in a relatively paternal environment,” so we understand that acceptance of our strategy might take time.

We don't want to stop research into what pharmacy will look like in 10 years. We just want to find out how good we can be today. Patients need us to figure this out sooner rather than later.