Twenty-two physicians were invited to take part in the study and nine agreed to participate. Two physicians did not have time and no response was received from eleven. As previously mentioned, data saturation was reached after nine interviews so no attempts were made to contact these physicians. The characteristics of the participants are described in Table
2. Most physicians worked in internal medical wards, and a few physicians in a geriatric ward. On average physicians had been working with clinical pharmacists for 4.8 years (range 1–10 years).
Table 2
Participant characteristics
P1 | 30–40 | Male | 4.5 | 1 | 10–25 |
P2 | 40–50 | Female | 19 | 1 | 10–25 |
P3 | 30–40 | Female | 5 | 3 | 10–25 |
P4 | 30–40 | Male | 12 | 5 | > 25 |
P5 | 50+ | Male | 20 | 1,5 | 10–25 |
P6 | 40–50 | Female | 22 | 10 | > 10 |
P7 | 50+ | Male | 19 | 10 | > 25 |
P8 | 30–40 | Female | 8 | 2 | 10–25 |
P9 | 30–40 | Female | 7 | 6 | 10–25 |
The clinical pharmacy service
All physicians used positive terms to describe the clinical pharmacy service. Some highlighted the fact that they especially appreciated having had the opportunity to discuss each patient systematically with the pharmacist. However, physicians’ views varied; some mentioned that medication review is an important task they would like to perform themselves. But as it saves them time, they are happy to leave that task to the pharmacist. As one of the physicians noted: “It's a pretty big task to do it [medication review] for every patient, and you might wish that you had the time to do it yourself, but you just can’t cope with that, can you?” (P7).
A general view voiced by physicians in this study is that medication reviews are time consuming. Some mentioned that medication reviews are not given a high priority, as physicians have to maximize their time and therefore focus mostly on the acute medical problem. As one physician said, “You can't spend a whole day trying to figure out and read up on and find articles [about interactions] to help one patient.” (P6).
However, others stated that medication reviews not only “save them time” but when also done by a professional perceived to have “more knowledge of drugs”. This can be seen in the account from this physician: “It takes up a good-sized space and saves me a lot of time. Actually, that somebody who knows, and has experience, has gone through it in a structured way, gone through the medication lists.” (P4).
Another physician commented: “Then I think it has been very nice, because it has been a forum for discussion. Nobody has been pulling rank, instead it has been an opportunity to talk a little about the patient.” (P5).
Several of the physicians mentioned that medication review is an opportunity to learn more about drugs and medication treatment. Some of the participants commented that it has helped them become
“better physicians”.
“I believe that the work this pharmacist has done has been really good because it has become a revision and a learning process for us about, yes, interactions. It could be specific drugs, how they work together with other drugs or in combination with reduced renal function and things like that, and there is always a need to learn more about this.” (P2)
Following recommendations
Regarding the question of what kind of recommendations the pharmacist provides physicians with, the answers included: drug interactions, dose adjustments, side-effects, inappropriate drugs to certain patient groups (e.g. the elderly), drug changes, combinations of drugs, discontinuation of a drug, administration time, contra-indications, dose reduction and switching to drugs that are better suited based on the patient’s kidney and liver function. The recommendation that was most commonly mentioned was drug interactions. All physicians stated that the recommendations were clinically relevant, adequate and followed most of the time.
“Usually we say, ‘OK, good let’s do that’, and then we change according to [the pharmacist’s] recommendation. That is the most common, as [the pharmacist] has such sound advice. Sometimes there has been a discussion about a very important drug that has been prescribed and so on, and then we discuss whether there are other options to consider.” (P3)
Physicians provided different reasons as to why a recommendation was not followed. For example, some mentioned that they had already consulted another specialist, while others said they had already thought about the suggestion before the pharmacist mentioned it and had already decided not to do anything about it. Some of the younger physicians noted that they follow the recommendations made by other specialist or a more experienced physician rather than the one provided by the pharmacist.
Patient outcomes
All physicians perceived medication reviews performed by a pharmacist to have a positive impact on patient outcomes. Some mentioned that while some benefits could be obtained while the patient is in the hospital, the impact of medication reviews once the patient is discharged from hospital cannot be determined. Patient outcomes attributed to the clinical pharmacy service included: reduced risk of side-effects and interactions, and reduced length of stay. Both physicians who have been practising medicine for a long time and those who have been practising for a shorter time shared this view. One physician also described the clinical pharmacy service as an opportunity to perform a “
safety check” on the patients’ medication treatment.
“The patient safety you can observe (…) is reduced side-effects, reduced risk of interactions and so forth.” “The better the medications are balanced for the patient, the better it is. (…) I believe it is a patient-safety issue.” (P4)
Service factors and awareness
When participants were asked what they thought the pharmacist does on the ward, they gave different answers. Some specified many different tasks while others did not. There were differences based on the experience and years working with the pharmacists. Many of the older physicians were able to describe the tasks performed by the pharmacists before the ward round. However, most of the younger physicians described what happens during the actual ward rounds. One of the younger participants mentioned “I don’t really know what she [the pharmacist] does.” (P3).
Tasks that were described included: the pharmacists look at patients’ medical records, share drug knowledge, establish a protocol for each patient, suggest things that need to be checked (e.g. laboratory values, kidney function) and highlight problems that have been found in a patient’s medication treatment. If all the comments offered by the physicians are combined, this provides a close description of what a medication review is and what the pharmacist generally does on the ward.
However, most physicians were unclear about the structure of the service and how it operates. For example, they did not know how to contact the pharmacist, when and how often the pharmacist visits the ward or if the pharmacist is still coming to the ward. This was more frequent amongst physicians that rotate between wards.
Suggestions to improve the service
The majority of physicians provided suggestions on how to improve and expand the clinical pharmacy service. These included: being able to call the pharmacist during working hours, education about drugs and pharmacological treatments, increasing the frequency of ward visits by the pharmacist, presentations on findings e.g. things physicians often miss, DRPs. The majority mentioned that they want the service to continue, and some physicians said that they want the service to grow and be implemented on other wards.
“I believe that it is really good when [the pharmacist] comes, and that [the pharmacist] is a good asset and I hope that it will at least continue to be like this. That [the pharmacist] will come, that [the pharmacist] will be able to come more frequently.” (P3)
Information and cooperation were described as key elements. As one physician explained, they “… find a good form for it. That is, the physicians, and all staff, need to know that we now have a pharmacist here. So that they know it. So that I don’t start to look into things first, and then suddenly there is another person there who has a lot of good information. The cooperation must be formalized so that you know that on certain days there is this possibility, or at this time or that time.” (P6).
The clinical pharmacist
The value of the pharmacist in hospital wards
All physicians commented that it is very positive to have a pharmacist on the ward. As described by this physician: “I believe that they [the pharmacists] have been an asset on the ward in an area that we, and by ‘we’ I mean physicians, often don’t have satisfactory knowledge in, i.e. drugs, interactions and such things. So I believe that they have contributed in a good way to the goal.” (P3).
Participants described clinical pharmacists as “helpful” and “supportive”, an “asset” and “a resource”, but also as “an expert that gives advice”, “a collaboration partner”, “a colleague” and “a colleague that has a special interest”. Some of them also mentioned that pharmacists in general are underused in terms of the qualifications they possess. As illustrated by this physician’s comment: “I believe that pharmacists in general are underused in Sweden. They study at university for ages and then sell medications at the [community] pharmacy.” (P4).
The majority of the participants also mentioned that they did not know how much knowledge a pharmacist actually has until they started interacting with them. As expected, this differed depending on the physician’s experience with pharmacist-provided services. Before the service was implemented in these wards the majority of the participants considered the pharmacist’s main role is to work in a community pharmacy. As one physician described: “Before I have always looked upon the pharmacist as someone working in a [community] pharmacy.” (P3).
Most participants reported that they have interacted with pharmacists only during ward rounds or when community pharmacists have called them. In Sweden, community pharmacists contact the prescribing physician if questions about the prescribed medications arise. Some of the older physicians reported that besides the hospital wards they have interacted with pharmacists in drug and therapeutic committees (DTCs) or when using the service provided by the drug information centre at Västerbotten County Council (ELINOR). Physicians who had interacted with pharmacists in DTCs or ELINOR before the service was implemented in the hospital had more understanding of what knowledge pharmacists possess. This can be seen in the account of this physician: “I have always had a vague idea about what a pharmacist does, until I participated in a drug and therapeutic committee. (…) After that I got a better understanding of what a pharmacist does. (…) They have much longer and more in-depth training than what I had believed.” (P6).
The clinical pharmacist as the drug expert
Physicians often brought up drug knowledge during the interviews, both their own knowledge and that of the pharmacist. All the physicians described pharmacists as “drug experts” and repeatedly mentioned the pharmacists’ pharmaceutical knowledge. In particular, drug interactions and problems that emerge as a result of these were mentioned by most of the participants. Some of the younger participants mentioned that they themselves lack pharmaceutical knowledge or do not have as much knowledge as they would want. In contrast, older participants described how pharmacists complemented their own knowledge about drugs. As one physician said, “Well [the pharmacist] has considerably deeper knowledge than I do about specific pharmacology, so to speak. And especially about interactions and such things that I’ve certainly read about some time ago but have forgotten.” (P7).
Professional relationships
During the interviews the majority of physicians mentioned that they value the opportunity to interact with different health care professionals as they feel that each one can contribute with their expertise to patient care.
“Like on the rounds, that you sit down with a physician, and a nurse, and an assistant nurse and the pharmacist. And everyone contributes with their expertise. The assistant nurse with nursing care and the physician with a little medical knowledge, and the pharmacist who has pharmaceutical knowledge. So all the pieces in the puzzle are there.” (P3)
“I believe it is splendid [to have different professions present during ward rounds]. Yes, we have different approach angles to the patients’ problems. So that other things can crop up that you have not really thought of.” (P7)
When talking about collaboration, some of the physicians mentioned personal traits such as: “you have to be humble”, “open to other individuals’ perspectives so that you can get along when you have different opinions”, “you cannot be a dictator” and “cannot take suggestions as criticism”. According to these physicians, these characteristics are the basis of good teamwork.
“You can’t take this as some sort of criticism. Instead, this is a really good opportunity to go through the medication lists with somebody who knows this on her five fingers.” (P5)
Most physicians’ described that collaboration is valued but at the same time they described how ultimately they make the final decisions on how to treat patients, or as described by this physician: “I have the final say”. Physicians also commented on how they are used to managing things, making evaluations, calculating risks and determining the best way to treat patients. Most of the physicians see the pharmacist as part of the team. However, a couple of participants mentioned that if continuity improved (i.e. the pharmacist was available every day) they would be part of the team. A couple of participants also mentioned that continuity is important “so you learn to know each other”.
Professional barriers
All of the physicians pointed out that they themselves do not have any barriers to working with a pharmacist. However, there was a difference between how younger and older physicians describe this. All but one of the younger physicians mentioned that some of their senior colleagues might have difficulties working with pharmacists. One participant mentioned that this is a new way of collaborating and “new things are not always viewed as positive”. Another participant reported that they have noticed tensions between their colleagues and the pharmacists based on comments some physicians sometimes make. Some of the young participants also mentioned that they have not experienced tensions but believe that they could exist.
“Some physicians appreciate this too, and some physicians believe that [the pharmacist] maybe is a little too skilled as [the pharmacist] checks everything to do with drugs and interactions and they want to override what [the pharmacist] says sometimes.” (P1)
Older physicians however described that: “I have no barriers”, “I don’t think that anybody has experienced that [barriers]”, “barriers exist between all professional roles”, “it is all about the person involved” and “it all depends on how things are put forth”.
Some of the participants mentioned that personal traits and the “having the right approach” are important for pharmacists that work in hospital wards. According to these participants pharmacists must not be too demanding and not comment on everything they find on a patient. One participant noted that “physicians are people of habit”. Some physicians described how change could be hard, especially when challenging clinical autonomy. One physician reported: “They [physicians] don’t want to be told what to do; you want to decide for yourself and some have more difficulties taking advice than others.” (P1).
Even though all physicians claimed not to have barriers, some of their comments convey a somewhat different view. One physician said: “Only physicians have knowledge of how to treat patients”, only physicians know “what works in real life”. Some also mentioned that pharmacists only have “theoretical knowledge”. One physician commented: “As a physician I have much more, and also nurses and assistant nurses, we all have more experience of working with a whole patient, with a human. While I can feel that the pharmacist’s point of departure is a little more of a theoretical one.” (P6).