Responses to "Is it time to start teaching basic diagnostics?".

To the Editor. We read the viewpoint article by Romanelli and Jones with considerable interest and wholeheartedly applaud and endorse their perspective.1 However, we find it ironic that it took 3 to 4 decades for it to resurface on the pharmacy profession “radar screen.” Forty years ago pharmacists in the Indian Health Service (IHS) demonstrated that pharmacists could be taught differential diagnosis and effectively function as primary care providers.2,3 The goal of the program was to use pharmacists to diagnose and treat high volume, acute, ambulatory illnesses and selected, common, chronic diseases requiring medication as the primary treatment. A subsequent development from this grant-funded pilot program was the IHS Pharmacist Practitioner Training Program (PPTP), based at the Phoenix Indian Medical Center.4 The IHS PPTP ultimately trained over 60 pharmacists. It used a curriculum very similar to that advocated by Romanelli and Jones.1 The pharmacist graduates of this program practiced at their home service units in a primary care role, under individualized standing orders and proficiency certification task lists. The training program and associated expanded pharmacist roles in the IHS have been described in several publications.4-7 The skills taught in the PPTP are those needed currently to effectively provide high-quality self-care advisor services in community practice, as well as those needed to provide disease management services in ambulatory care. Based on the success of the grant and the training program, Allen J. Brands, Chief Pharmacist of the Indian Health Service at the time, tried to advocate for similar expanded roles to national pharmacy associations and pharmacy educators for almost a decade.3 Unfortunately, these concepts were overwhelmingly rejected, ironically, by the very people who should have accepted, supported, and implemented them. Brands offered the completely developed and refined PPTP training manual and IHS pharmacist practitioners to train faculty members and assist in course design at no charge. Unfortunately, these generous offers were also rejected, many times with inappropriate animosity towards Brands. While the authors are correct, current doctor of pharmacy programs do expose students to diagnosis, in most cases critical material is not taught with methods that have been shown to be effective for training of physicians, nurse practitioners, and physician assistants. Therefore, current pharmacy students have incomplete preparation for a primary care role. Experts in medical education have advocated that by using just history-taking skills and usually only the observation/inspection portion of physical examination in conjunction with appropriate symptom-based diagnostic schemata, a correct diagnosis can be made in more than 90% of cases.8 More detailed physical assessment, laboratory studies, imaging, and other diagnostic procedures often only confirm the diagnosis. There are several missing pieces in most college of pharmacy curricula, relative to the teaching of diagnostic skills. The 2 most important deficiencies are optimal history-taking skills and diagnostic schemata for pattern recognition. Next, many colleges lack the necessary physical facilities, including properly equipped examination rooms. Also, as was the case 40 years ago, there is a paucity of pharmacist faculty members who have the training and experience to teach appropriate physical assessment and differential diagnosis. Using nonpharmacists to teach these skills has met with limited success, primarily because they do not understand how pharmacists would use these skills. Dual-degree faculty members like Jones could be a potential solution. In addition, the absence of a textbook directed at pharmacists’ needs for basic differential diagnosis skills will impede implementation. Finally, there are limited sites available for primary care clerkships, where pharmacists diagnose and prescribe. Realization and implementation of these concepts will require a philosophical shift within academia. Many schools focus on teaching pharmacists to advise or recommend therapy to other healthcare providers regarding medication. However, this is often done only as a part of therapeutics course work. Often it is done in a relative vacuum, without providing instruction on several critically necessary skills, especially, optimal history taking, appropriate approach to the patient, and differential schemata. Mastery of these skills would make the students both more confident and more competent to establish a likely diagnosis and recommend appropriate referral and/or management. While there are few reports about teaching differential diagnosis, since 1997 the University of Arizona College of Pharmacy has taught an 80-hour required course in differential diagnosis called Patient Assessment. Since 1999, a similar 80-hour required course in differential diagnosis and physical assessment has been taught at Oregon State University, College of Pharmacy. Both courses were designed by the authors, who are graduates of the IHS PPTP. The courses are roughly modeled after the IHS PPTP and more than meet the criteria established by Romanelli and Jones. Descriptions of the course, specific course segments, plus the teaching methodology used have all been freely shared throughout the profession in the form of presentations at numerous professional meetings. These materials have also been shared with dozens of colleges of pharmacy. Unfortunately, the response from academia has generally been lukewarm, many times with the cited reasons the same as those listed previously as deficiencies. Finally, the authors were concerned about opposition from other health professions as a barrier to overcome in the implementation process. Unfortunately, based on previous experience, the biggest barrier may be from within the profession of pharmacy itself, including academia. We applaud the authors and sincerely hope that the profession does not wait another 40 years to consider evaluation and implementation of this important topic.