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Physicians' Perceptions of Communication with and Responsibilities of

Pharmacists

Article in Journal of the American Pharmaceutical Association (1996) · September 2000

DOI: 10.1016/S1086-5802(16)31102-0 · Source: PubMed

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• RESEARCH

Physicians' Perceptions of
Communication with and
Responsibilities of Pharmacists
Paul L_ Ranelli and June Biss

Objective: To understand physicians' perceptions of (1) their communication with pharmacists, (2) pharmacists' professional duties,
and (3) the degree of responsibility with which pharmacists perform these tasks. Design: Structured interviews with convenience sam-
ple of physicians in phase 1; written survey mailed to convenience sample of physicians in phase 2. Participants: Six physicians in
Wyoming in phase 1, and 313 primary care physicians who were members of the Wyoming Medical Society in phase 2. Main
Outcome Measures: Physicians' attitudes and experiences related to their interactions with pharmacists and their perceptions about
pharmacists' responsibilities. Results: Usable surveys were returned by 176 physicians (response rate = 59.1%). Age ranged from 27 to
86 years (mean ± SD = 43.5 ± 10.4 years), 79.5% were men, and 50.6% were in family practice. Almost 25% had personal contact with
pharmacists regarding patients' medications four or more times daily, but 20.6% rarely had this type of contact. Pharmacists contacted
physicians' offices regarding prescription refills frequently, with 28.7% reporting 10 or more contacts daily. For 79.2% of respondents, an
office nurse had the most contact with pharmacists. Respondents were most comfortable with pharmacists' responsibilities of catching
prescription errors (88.0%), providing patient education (65.1%), suggesting nonprescription medications (63.4%), and suggesting pre-
scription medications to physicians (52.0%). Respondent's age was negatively correlated with three functions related to pharmacothera-
peutic regimens: designing regimens, monitoring effects of failed regimens, and monitoring outcomes. The most common negative
experiences with pharmacists involved pharmacists' scaring the patient, dispensing unauthorized refills, and making inappropriate com-
ments in the presence of patients. Conclusion: Future research with a larger, more representative sample of physicians will help
explain this dynamic relationship. These preliminary results should be useful in training future physicians and pharmacists.

JAm Pharm Assoc. 2000;40:625-30.

Patient care pharmacy---Qr pharmaceutical care--is the synthe-
sis of a pharmacist's distributive and informational responsibili-
ties into a responsibility for drug therapy. A pharmacist practicing
under this model (1) advises and consults physicians and patients;
(2) accepts responsibility for implementing therapeutic plans,
including the supply of drug products; and (3) monitors patient
progress and drug-related outcomes. The pharmacist' s primary
relationship is with the patient as a therapist; the relationship with
the physician is collegial as a co-therapist.
If the quality of patient care under this model is to improve,
Received September 9, 1999, and in revised form December 9, 1999.
Accepted for publication February 1, 2000.
Paul L. Ranelli, PhD, is associate professor, social and behavioral phar-
macy, School of Pharmacy, University of Wyoming, Laram ie. June
Biss, MS, is dental hygiene instructor, Sheridan College, Sheridan,
Wyo. At the time of this study, she was a graduate student in the Uni-
versity of Wyoming School of Physical and Health Education.
Correspondence: Paul L. Ranelli, PhD, University of Wyoming, School
of Pharmacy, P. O. Box 3375, Laramie, WY 82071-3375. Fax: 307-766-
2953. E-mail: pranelli@uwyo.edu.
especially in nonhospital settings, it is necessary to modify or
bridge the communication gaps between pharmacists and physi-
cians. The contemporary electronic options that are making their
way into practice of pharmacy, although not without pitfalls, may
help improve communication.' Generally, however, pharmacists
and physicians still communicate largely through written or tele-
phoned prescription orders, which means that in most cases phar-
macists have only a limited amount of information with which to
evaluate a patient's drug therapy. Similarly, with communication
so limited, physicians are unable to benefit from a pharmacist's
suggestions about drug therapy. Bridging the gap would facilitate
the transfer of information about drug effectiveness, drug interac-
tions, patient compliance, and prevention of medication-related
errors, especially in light of a recent Institute of Medicine report
that drew attention to the impact of the global issue of medical
errors.2
Given the increased complexity of pharmacist-physician inter-
actions, the changing modes of health care, and the ideal role of
the pharmacist as part of an integrated care team, accurate and

Vol. 40, No.5 September/October 2000 Journal of the American PhannaceuticaI Association 625
 RESEARCH Physicians' Perceptions
satisfying communication is crucial. Before effectively bridging
the gap, a stronger understanding of the physician-pharmacist
relationship and patterns of communication is needed. According-
ly, this study focuses on physicians' perceptions of pharmacists.
In our review of the literature on pharmacist-physician com-
munication, we identified articles noting the presence of the com-
munication gap,3.4 why the gap exists,5-7 why pharmacists and
physicians should bridge this gap,6-9 how this might be done, 10--15
guidelines for pharmacists providing pharmaceutical care,16 and
physicians' views of pharmacists as patient advocates. 17-19 These
studies provided insight into the pharmacist's perspective of this
communication, but studies examining the physician's viewpoint
were mostly anecdotal.
Insufficient communication between pharmacists and physi-
cians occurs for several reasons. One barrier that has been cited is
pharmacists' expressed lack of confidence in their ability to per-
suade physicians to accept their recommendations. 6 Another pos-
sible cause is irIeffective or needless communication initiated by
pharmacists, which makes physicians less willing to listen to
pharmacists during future interactions. 5 In addition, physicians do
not see pharmacists as readily available drug information special-
ists because of factors such as location7 and telephone delays. 5
The irIcreased interprofessional communication seen in certain
situations, for example, when pharmacies are located in physician
'offices7 and health maintenance organizations,6 has produced
drug therapy that is safer, more effective, and less costly. Further-
more, multiple studies report that physicians want pharmacists to
communicate with them. In one study, physicians recommended
that pharmacists notify them first, even before the patient, when
possible problems with drug dose, allergy, or interaction arise. 8 In
another study of physician opinion, the physicians believed that
pharmacists were competent and knowledgeable and thus should
be doing more than just dispensirIg medication. 9
The purpose of this project was to help practitioners and
researchers understand more clearly physicians' perceptions of
pharmacists, especially interprofessional communication, phar-
macists' responsibilities, and availability issues. The pharma-
cist-physician relationship has both a glorious and less-than-
glorious past and present. 20 Beginning to understand several intri-
cacies of the relationship from the physician' s poirIt of view will
help pharmacists, organized pharmacy, and physician groups
work toward a better future helpirIg patients to make the best use
of their medications.
Objective
The objective of this study was to understand physicians' per-
ceptions of (1) their communication with pharmacists, (2) phar-
macists' professional duties, and (3) the degree of responsibility
with which pharmacists perform these tasks.
626 Joumal of tile Ameriam Pharmaceutical Association
Methods
This study was conducted irI two phases. First, six physicians
were interviewed in an effort to identify important issues affect-
ing physicians' interactions with pharmacists and their percep-
tions about pharmacists' responsibilities. Second, a survey was
developed based on the information collected irI phase 1 and sent
to 313 physicians in Wyoming.
Physician Interviews
One-on-one interviews were conducted with a convenience
sample of six physicians in Wyoming (population 480,000), five
of whom were men. One physician practiced in Casper (popula-
tion 50,000), the other five in Laramie (population 27,000). Three
were family practice/general practitioners, two were inteinists,
and one was a urologist. They were recruited based on personal
acquaintance with the investigators, professional recommenda-
tions, and availability.
A set of open-ended questions based on the literature review and
the authors' practice experiences probed physicians' interactions
with pharmacists and their perceptions about pharmacists' responsi-
bilities. The irIterviewer (JB) participated in the discussion and
recorded responses by taking notes. The physicians were assured
that their responses would be kept confidential. A qualitative analy-
sis was used to identify common themes in the irIterviewers' notes.
Physician Survey
A survey instrument consisting of 11 substantive questions
plus 3 background questions was developed. The questions were
primarily based on information collected irI phase 1, but several
items that represented the pharmacist's role irI pharmacotherapy
were abstracted from the American Society of Health-System
Pharmacists guidelines on a standardized method for pharmaceu-
tical care. 16 Surveys were numbered to help track respondents,
but this number was not used to analyze individual responses.
Physicians were assured of confidentiality.
This survey was mailed in May 1997 to 313 physicians who
were members of the Wyoming Medical Society and identifiable
as practicing in primary care specialties (general practice/family
practice, gynecology and/or obstetrics, internal medicine, and
pediatrics). Physicians were asked to return the completed survey
irI an enclosed self-addressed, stamped enveloped. A second sur-
vey was sent in August 1997 to all nonrespondents.
Data Analysis
Descriptive statistics were computed for all variables. To deter-
mine whether the respondents' degree of comfort with specific
pharmacist functions was correlated with the respondents' age,
Pearson product moment correlations were calculated, where the
a priori level of statistical significance was P ~ .05.
SeptemberlOctober 2000 Vol. 40, No.5

Results
Physician Interviews
From the six physician interviews, eight common themes
emerged: who communicates with phannacists, communication
roadblocks, perceived threats, phannacist responsibility, phanna-
cotherapeutic regimens, patient education, type and proximity of
phannacy, and availability of phannacists.
Some representative responses from the physicians during the
interviews follow:
• "Some physicians may feel that their professionalism is being
questioned when pharmacists call them about discrepancies.
I think this depends a lot on the physician's personality type."
• "On occasion, phannacists have made an inappropriate com-
ment about a medication or given the patient too much infor-
mation. This has caused some of my patients to question the
medication I have prescribed, and at times the patient has even
stopped taking the medication. It becomes a problem for me
because then I have to totally re-educate the patient on the
medication. "
• "I do some communicating with the phannacists [in the area],
but my nurse does a large portion of the communication, espe-
cially when it comes to refills."
• "Pharmacists are definitely professionally obligated to catch
and prevent prescription errors . They should not have an
increased role in treating minor illnesses. They have not been
trained in this area, and they may not be able to properly do
clinical assessment."
• "I think the ideal setting for communication between phanna-
cist and physician is the hospital phannacy. I communicate
considerably with the pharmacists in the hospital. Easier
access on both parts makes communication more effective."
• "Trying to contact a pharmacist on the weekend or after hours
can be a problem. Sometimes I have to send my patients to the
emergency room to get their medication, and this ends up cost-
ing the patient more money. They used to have on-call phar-
macists [in the area] for the weekends. I think this would be a
great thing to get going again."
Table 1. Frequency of Communication Between Pharmacists and Physicians (% of Total)
Physician-Pharmacist
Contact Regarding
Patient's Medications
Approximate
Frequency (n - 175)
20.6
Never or rarely
54.9
1-3 times/day
4-6 times/day 13.1
7-9 times/day 11.4
10 or more times/day
Vol. 40, No.5 September/October 2000
Physicians' Perceptions RESEARCH
Physician Survey
Of the 313 surveys sent, 15 (4.7%) were returned as undeliver-
able or unusable. Of the 298 delivered, 176 completed surveys
were returned, for a response rate of 59.1%.
The mean (± SD) age of the respondents was 43.5 ± 10.4 years,
with a range of 27 to 86 years. Four-fifths (79.5%)' were men.
One-half worked in family practice (50.6%), and the other half
were distributed among internal medicine (17 .0%), pediatrics
(14.2%), obstetrics-gynecology (9.7%), and other specialties
(8.6%).
As shown in Table 1, 20.6% of the respondents never or rarely
had personal contact with a phannacist regarding a patient's med-
ication, while 24.5% had this type of contact with a pharmacist
four or more times daily. Only 13.2% of the respondents had a
phannacist contact them with a suggestion regarding a new pre-
scription, and they reported this happening one to three times dai-
ly. Phannacists had plenty of contact with the physicians' offices
regarding prescription refills, with 28.7% reporting 10 or more
contacts per day; 10.3% never or rarely had phannacists call the
office for refill authorization. For 79.2% of the respondents, nurs-
es were the office staff having the most contact with pharmacists
about medication, and about one-half ranked physician assistants
or nurse practitioners as having the second most contact with
phannacists (47.6% and 52.0%, respectively).
Phannacists were accessible to physicians; 86.9% reported not
having instances when they wanted to speak to a pharmacist
regarding patient care but were unable to do so. When asked
about the ideal location of a pharmacy for communication pur-
poses, 19.9% indicated a desire to have a phannacist who prac-
tices in their office, 23.0% thought a phannacy in the same build-
ing was ideal, and 57.1 % preferred a pharmacy in a different, yet
accessible, building. Respondents rated off-hours availability of
phannacists for medication needs and consultation as 2.3 ± 1.1,
where 1 =, availability is already adequate and 5 = significant
change in availability is needed.
According to 78.7% of respondents, physicians have the prima-
ry responsibility for the majority of patient education regarding
medications (see Table 2); 24.9% and 58.4% thought that phar-
macists have primary and secondary responsibility for patient
education, respectively. Almost three-fourths considered nurses
Pharmacist Contact
with Physician
Regarding New Pharmacist Contact
Prescription with Office for
Suggestions Refill
(n = 174) (n = 174)
86.8 10.3
13.2 32.8
17.8
10.3
28.7
Journal of the American Pharmaceutical Association 627
RESEARCH Physicians' Perceptions

Table 2. Rank Order of Professional Having Responsibility
for Patient Education en = 176)
Responsibility (%)
Professional Primary Secondary Tertiary
Physician 78.7 18.4 2.9
Pharmacist 24.9 58.4 16.8
Nurse 5.2 22.5 72.3
as having the least amount of responsibility for patient education.
When asked whether they were aware of occasions when they
thought patients were given too much information about medica-
tions, respondents reported a mean ± SD of 2.1 ± 0.8 on a scale of
1 to 5 where 1 = never happens, 3 = happens about half of the
time, and 5 = always happens.
Table 3 shows the respondents' feelings about the degree of
responsibility exhibited by pharmacists for various functions.
Respondents were most comfortable with pharmacists catching
and preventing prescription errors (88.0% comfortable). The
majority of respondents were also comfortable with pharmacists
providing patient education (65.1 %), suggesting the use of non-
prescription medications (63.4%), and suggesting the use of cer-
tain prescription medications to physicians (52.0%).
For four functions, 36% to 42% of respondents reported being
either uncomfortable or moderately comfortable: pharmacists sug-
gesting the use of certain prescription medications to patients, mon-
itoring the effects of pharmacotherapeutic regimens when the regi-
men fails, monitoring outcomes of pharmacotherapeutic regimens
and plans, and tending to minor illnesses. As to pharmacists'
responsibility in designing pharmacotherapeutic regimens, respon-
dents were approximately evenly divided across the three cate-
gories of uncomfortable, moderately comfortable, and comfortable.
Age was negatively correlated with respondents' degree of
comfort with t4ree functions related to pharmacotherapeutic regi-
mens: designing pharmacotherapeutic regimens, monitoring the
effects of pharmacotherapeutic regimens when the regimens fail,
and monitoring outcomes from pharmacotherapeutic regimens and
plans (r =-0.226, -0.230, -0.172, respectively, P :::; .05). For these
three functions, the respondent's degree of comfort decreases as
age increased.
As shown in Table 4, 52.3% of respondents reported having
had an experience where a pharmacist reportedly tried to be help-
ful by educating a patient, but actually scared the patient out of
taking the medication. More than one-third of respondents had a
negative experience in which a pharmacist gave a patient the
wrong drug or wrong dosage (42.0%), reportedly made an inap-
propriate comment about a prescribed medication in the presence
of the patient (39.8%), and refilled a prescription not indicated
(33.0%) for refill. The most common negative experiences were
scaring the patient (28.3%), dispensing unauthorized refills
(26.4%), and making inappropriate comments (21.7%).
Discussion
Overall, this group of physicians was not willing to give up
responsibility for patient education, but they recognized the phar-
macist's role in that process. The physicians saw themselves as
having primary responsibility (78%) for patient education, but
65% were comfortable with pharmacists providing patient educa-
tion-this was not surprising, since 83.2% of respondents rated

Table 3. Respondents' Feelings About Degree of Responsibility Exhibited by Pharmacists for Various Functions8

% of Physicians (n = 176)b

Moderately
Pharmacist Function Uncomfortable Comfortable Comfortable Mean (SO)
Providing patient education 8.0 26.9 65.1 3.77 (0.99)
Suggesting use of nonprescription 9.7 26.1 63.4 3.77 (0.98)
medications
Suggesting use of certain prescription 43.7 38.0 18.4 2.62 (1.15)
medications to patients
Suggesting use of certain prescription 16.0 32.0 52.0 3.55 (1.11)
medications to physicians
Tending to minor illnesses 41.3 36.8 21.8 2.69 (1 .17)

Catching and preventing prescription errors 0.6 11 .4 88.0 4.45 (0.72)

Designing pharmacotherapeutic regimens 31.2 33.5 35.4 3.01 (1.21)

Monitoring the effects of pharmacotherapeutic 42.7 39.0 18.3 2.62 (1.10)

regimens when the regimen fails
Monitoring outcomes of pharmacotherapeutic 42.4 36.8 20.8 2.69 (1 .11)
regimens and plans

SO = standard deviation.
"As measured on a 5-point modified Likert scale, where 1 = uncomfortable, 3 = moderately comfortable, and 5 = comfortable.
bResponses of 1 or 2 were collapsed into the uncomfortable category, and responses of 4 and 5 were collapsed into the comfortable category.

628 Journal of the American Phannaceutical Association SeptemberlOctober 2000 Vol. 40, No. 5

Table 4. Respondents' Negative Experiences with Pharmacists' Services
Experience
Reportedly tried to be helpful by educating patient
but actually scared patient out of taking medication
Gave patient wrong drug or wrong dosage
Reportedly made inappropriate comment about a prescribed
medication in presence of patient
Refilled prescription not indicated for refill
Refused to order a medication not in the formulary
Changed directions on refills inappropriately
pharmacists as having primary or secondary responsibility for
patient education.
Slightly more than one-half of respondents had experience with
pharmacists giving information that scared patients out of taking
medication, and 28% said this was their most common negative
experience with pharmacists. (Presumably, physicians heard
reports of this from patients rather than experiencing it firsthand.)
When asked whether they were aware of occasions when they
thought patients were given too much information, 76% thought it
happened less than half of the time. Therefore, just because this is
reported here as the most common negative experience with phar-
macists does not mean that it happens routinely.
Also, respondents indicated in their comments that they had
had negative experiences with pharmacists that were not men-
tioned in the survey; for example, a pharmacist failed to put an
expiration date on a prescription bottle, gave a drug that was not
prescribed, did not refill a medication because of lack of insur-
ance coverage, tried to and did substitute generics without the
physician's permission, and inappropriately refused to fill a pre-
scription. By including these issues in subsequent surveys, we
may be able to identify more clearly the most common negative
experiences related to pharmacist-physician interactions. It would
also be interesting to determine physicians' perception of the
most important negative experience, so that efforts could be made
to rectify those situations.
Only 13.2% of respondents reported having a pharmacist con-
tact them with a suggestion regarding a new prescription, and this
occurred 1 to 3 times daily. Eighty-four percent of the respon-
dents were at least moderately comfortable with pharmacists sug-
gesting the use of certain prescription medications to physicians,
however, which is in line with the overall findings by others. 8- 1O
Perhaps pharmacists are less comfortable than physicians with
this aspect of their duties, and better communication between pro-
fessionals may help this.
The negative correlation between physician age and degree of
comfort with pharmacists designing and monitoring pharma-
cotherapeutic regimens, also noted by Bradshaw and Doucette, 17
is interesting. This negative relationship could simply reflect the
Vol. 40, No.5 September/October 2000
Physicians' Perceptions RESEARCH
% Reporting Most Common Experience
Experience % of Total
(n = 176) No. (n - 106)
52.3 30 28.3
42.0 7 6.6
39.8 23 21.7
33.0 28 26.4
18.2 9 8.5
9 .7 3 2.8
younger physicians' acceptance of the pharmacist's enhanced role
in pharmaceutical care as espoused by the pharmacy profession
since the early 1980s. Alternatively, older physicians may not be
familiar with the relatively new term "pharmacotherapeutic," and
therefore their responses may reflect a lack of understanding
rather than a lack of comfort with the pharmacist's role. In future
research, it will be important to define all terms so that respon-
dents are on similar footing when answering.
Pharmacists could help bridge this gap by identifying what out-
comes are valued by a particular prescriber and targeting commu-
nication to areas relating to these outcomes. According to a physi-
cian survey that focused on physician acceptance of pharmacist
recommendations in skilled nursing facilities, the significance of
a recommendation to the physician was of highest importance,
followed by the communication method used by the pharmacist. 10
When the problem noticed by the pharmacist was serious, the
telephone was mentioned as the most acceptable method of com-
munication. Furthermore, the authors asserted that pharmacists
should learn the communication preferences of individual physi-
cians, because one strategy may not be universally acceptable.
Before making therapeutic suggestions, however, pharmacists
should identify pertinent reference material and have it on hand
during the call in case it is needed to persuade the physician. I 1,13 In
a study on physicians' attitudes and beliefs about using the pharma-
cist as a source of drug information, physicians were most influ-
enced by the type of question they received and their belief about
the pharmacist's ability to answer the question. 12 Therefore, phar-
macists should inform physicians about the scope of their abilities.
Pharmacists could encourage physicians to call them by instituting
an unlisted telephone number exclusively for use by physicians. 5
We believe that many of the issues relating to physicians' per-
ceptions of pharmacists relate to communication among physi-
cians, pharmacists, and patients. The most salient and prevalent
influences on medication-taking are beliefs that people hold about
their medication and about medications in general. These beliefs
have their roots in medication-communication scenarios, includ-
ing the level of understanding patients have about their medica-
tion, motivational cues and strategies to promote adherence, and
Joomal of the American PhannaceuticaJ Association 629
 RESEARCH Physicians' Perceptions
feedback from providers, family, friends, and the media. These
beliefs may be at odds with the best evidence from medical sci-
ence and consequently receive little, if any, attention from phar-
macists or physicians. Yet they are fmnly rooted in common per-
sonal, family, and cultural experiences. For pharmacists and
physicians simply to reaffirm the views of medical science and to
dismiss or ignore these beliefs, which are formed from various
levels of oral and written communication about medication, is to
fail to help patients make the best use of their medications.
Limitations
The results of this study are not generalizable to all physicians,
since the sample was small and the physicians were located only
in Wyoming. Also, there may be potential response bias because
of the 59.1 % response rate.
Because our development of the survey relied heavily on
responses from the physician interviews, issues may have been
overlooked given the small number of physicians interviewed.
For instance, some survey respondents noted several negative
experiences with pharmacists that were not included in the list.
Also, physicians ' perceptions of the most important negative
experience were not assessed.
The respondents may not have answered questions accurately
or honestly, even though confidentiality was assured. Reports
were not verified, although that may not be important, since the
study focused on physicians' perceptions.
Despite these limitations, we believe that these results provide
useful insight into physicians' perceptions of pharmacists.
Conclusion
While our fmdings cannot be generalized to al~ physicians, the
results offer some indication that physicians are open to pharma-
cists' responsibilities related to catching and preventing medica-
tion errors, providing patient education, and suggesting use of
nonprescription medications. The physicians in this study appear
to be receptive to having pharmacists contact them to suggest the
use of certain prescription medications. Future research with a
larger, more representative sample of physicians will help
researchers gain a better grasp of the dynamic relationship
between pharmacists and physicians. These preliminary results
should be useful in training future physicians and pharmacists b.y
revealing how one prominent provider views another on several
dimensions.
Supported in part by the American Pharmaceutical Association Research
Stimulation Grant Program and the Faculty Grant-In-Aid Program at the
University of Wyoming. Beyond grant support for the project, the authors
630 Joumal of the American Pbarmaceutiral Association
View publication stats
declare no conflicts of interest or financial interests in any product or ser-
vice mentioned in this article, including grants, employment, stock hold-
ings, gifts, or honoraria.
The assistance of the Wyoming Medical Society and the Wyoming physi-
cians who were interviewed is acknowledged. This work is dedicated to
the late Larry L. Fahlberg, PhD, who was an investigator on this project
until his tragic death in August 1998.
Presented at the American Pharmaceutical Association Annual Meeting,
Research Incentive Program, San Antonio, Texas, March 7, 1999.
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SeptemberlOctober 2000 Vol. 40, No.5