How Much of Modern Pharmacy Practice Is Wrong?

Ruminations on governing body recommendations and guidelines that dictate what pharmacists do.

History is not always kind.

I realized that fact on a recent trip to New Orleans with my wife. We were celebrating becoming 100% debt-free and 8 years of marriage, in a city warmer than our own, by about 40 degrees. I had no idea when I scheduled the trip that New Orleans is home to the first licensed pharmacy in the United States.

Our visit there provided a good history lesson. I saw compounds and tinctures from the past, and I felt like I was in school again. I re-learned silly practices, such as the conventions of using cocaine for tooth pain and opioids as a cure-all, as well as not labeling medicine packages. These days, of course, we think about medicine differently because science has progressed so much. I also learned about some things we got right, such as the calcified goat hairball, called a bezoar, that was used in drinking water to protect kings from getting poisoned. Upon recent study, it turns out that the bezoar contained a compound that deactivated arsenic.

The experience caused me to think about governing body recommendations and guidelines that dictate so much of what we do as pharmacists. In the early days of my career, those were the gold standard to me; they represented the ultimate truth. I realized, though, that these truths have become like a religion, and the problem is that these "religious truths" are constantly changing.

As medicine advances, the guidelines do. too. So here are some things to think about:

We often follow these guidelines as though there is no other option.

I realize sometimes as I am dealing with patients that I often operate with an unintended arrogance: the assumption that my way is the best way. I realize I can be medicine-happy. If we have a patient who has a very high A1c, we follow the guidelines that immediately encourage Metformin. Lifestyle changes are, of course, a strong recommendation, but deep down I believed that those would not work for most people. People need medications to appropriately handle disease.

We should consider the possibility that medicines are not always the answer.

I do not have absolute truth to base this on, but I feel like my religion of medicine has changed. We are learning that a hallmark of evidence-based medicine, randomized controlled trials, are not always right. Take rosiglitazone, as an example. Thousands of prescriptions were written before discovering that the medication was doing more harm than good. Now, we are choosing the best option, based on what we know, and doing what the best evidence suggests. But any day, new evidence could appear and clearly show that a medicine is more poison than cure. There are lessons to be learned from hindsight.

We should not claim to have all the answers.

We should acknowledge that medicine and science are more art than an absolute truth. Understand that I am not discounting guidelines or recommendations, as they are the best approaches we have right now. But realize, too, that 300 years from now, people will look back on our 2018 practices and consider them barbaric. They will consider our current treatments unscientific, the same way that we view the ancient practice of bleeding a patient.

All this makes me wonder how much of my pharmacy practice is wrong, and if it is, how will I know?

The truth is that randomized controlled trials are our best means to find answers. They reveal the dangers and problems with current practices and they give us additional information that we did not previously have. I discovered that my practice is influenced by dogma that very well could be wrong.

Medicine sometimes feels like a religion, but it should not be practiced as one.

We must tell patients that we are making decisions based on the very best information we have. We must explain that we base our decisions on what we think is best but that we do not have definitive answers to everything. I am discovering that medicine is a lot like parenting. We parent, based on the information we have, and we often wish we had known in the early years the things we know now. Just a few decades ago, doctors smoked in the delivery room. What else could we be doing blatantly wrong but not realize? We must let patients know that our very best advice is based on the simple truths that eating healthy foods and exercising are vital; those 2 choices are the best things they can do for their health. Beyond that, we are working largely by trial and error.

Do not treat medicine as the ultimate truth.

Medicine changes every year, as does our knowledge of our bodies and health. As a result, our medical practices change, too. We are constantly discovering new things, such as copper-infused scrubs that prevent the spread of bacteria and infection. In 50 years’ time, it may be required practice for medical professionals to wear protective clothing. As pharmacists, we should be willing to admit our limitations and let patients know with that we are making our best recommendations based on the information we have right at this moment.

We may someday look back and regret some of the medical practices we trusted, but we will never regret advising our patients to eat right and exercise. History will have no choice but to cut us a little slack.