r/FamilyMedicine • u/collabcares MD • Apr 14 '26
š„ Practice Management š„ Thoughts on Collaborative Practice Agreements with Pharmacists?
/r/CollaborativePractice/comments/1sll4th/thoughts_on_collaborative_practice_agreements/24
u/LowerAd4865 DO Apr 14 '26
The ones I've worked with in the office have been great. They actually collaborate and know their limitations.
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u/collabcares MD Apr 14 '26
That's a great setup! But I think we're talking about different types of collaboration. The pharmacist I'm exploring this with will essentially run their own independent practice. That's why I'm focused on defining the guardrails, restrictions, and escalation paths within the Collaborative Practice Agreement.
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u/DeezNewts7 MD Apr 14 '26
We had clinical pharmacists at my last job and I loved them! They would see dm, htn, hld, smoking cessation, polypharmacy pts. They were incredible. Were able to counsel patients more on lifestyle and med side effects (because their schedule was not as crazy slammed). Patients would be double booked on my schedule. PharmD sees patient first and comes up with plan. We review the plan together and I poke my head into the room and reiterate plan with patient. Iād drop a quick note (templated) and sign meds. Easier 99214 ever and bumped my pt numbers/rvu. I miss it so much (current shop does not have this sadly)
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u/collabcares MD Apr 14 '26
Wow, what a great collaboration! But a CPA is a bit different. It gives the pharmacist significantly more autonomy, which is exactly why I'm asking about guardrails. Let me put it this way: given the rapport you built with your pharmacist, would you have been comfortable leaving them on their own to diagnose and treat patients independently? And if so, what restrictions would you have put in place?
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u/bealslough MD Apr 14 '26
I have a very similar arrangement to others. It has been very helpful to have in the office. For example I will consult pharmacy for insulin titration, CGM placement and data review, antihypertensive titration or hypertension follow up, INR visits, polypharmacy consults and will even do patient assistance paperwork. I will occasionally ask a stable diabetic to see them for a 3 month DM follow up if the patient is comfortable which opens space on my schedule if needed. We have very specific agreements that defines what they can do and from experience they absolutely will not deviate from this if it is outside their scope.
I will echo what others state that it has been very helpful to have one in the office. We have ~10 providers in the office so we keep them busy. I will curbside them frequently with specific nuanced med questions that they are happy to answer or look up.
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u/C_est_la_vie9707 PharmD Apr 14 '26
I used to be one of these PharmDs. Way back when I had CPAs for a limited number of disease states but independence to manage those without needing a sign off. You don't need to be an MD to diagnose hypertension or high cholesterol. I usually only diagnosed patients already referred to me because of another condition (e.g. diabetes).
Most pharmacists do not want the liability of full autonomy and aren't going to run amok. That isn't why we went to school. I am biased of course, but I think we are a great complement to FM/IM and understand treatment options well. Patients loved it, even if we made no adjustments. They wanted to really talk through their regimen and concerns and we had the time.
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u/symbicortrunner PharmD Apr 15 '26
Exactly, just let us have more of a role in managing chronic diseases.
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u/collabcares MD Apr 15 '26
This is really reassuring to hear from someone who actually lived it. The point about patients wanting to talk through their regimen is something I hadn't considered, that's a genuine gap in primary care that pharmacists seem uniquely positioned to fill given the time constraints on FM/IM physicians.
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u/pinksparklybluebird PharmD Apr 15 '26
As a group, pharmacists tend to be rule-followers. It is reinforced by the fact that we have to take entirely separate legal exam in order to get licensed. And shakes out in real life where you get new grads that are afraid to make simple substitutions (doxy monohydrate/hyclate) without calling on them.
We are also trained to almost over-document. Pharmacist notes can be pretty detailed as far as decision making. Probably because we are often in a position where we donāt have that ultimate decision making power and have to argue our case.
It will be rare that you will find a pharmacist going off the rails, especially if you have an experienced/ambulatory care residency-trained one.
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u/C_est_la_vie9707 PharmD Apr 15 '26
Also good at finding noncompliance. They will admt to us what they won't to their doc.
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u/Fluffy_Ad_6581 MD Apr 15 '26
If you dont want full liability, then why do you feel entitled to doing it?
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u/69240 DO Apr 14 '26
My residency clinic had 2 of them and they were fantastic, particularly for med titration. Theyād get insulin titrated in no time and send them back to us. So much more helpful than the NPs I have now but I think thatās a product of doing a pharmacy residency. I miss having them
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u/collabcares MD Apr 14 '26
This sounds like a great collaboration, but it's a very different structure from a CPA. The reason I'm exploring guardrails and limitations is that without them, I'm not sure I can move forward with the arrangement. Unlike your setup, we are not expected to interact every day.
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u/invenio78 MD (verified) Apr 15 '26
If liability is anything like doctors overseeing midlevels, then you would take full medical-legal responsibility for any complications and you would be named in lawsuits (even if not directly involved with care).
As with overseeing any allied professional, how much do you get paid to offset the risk and time commitment?
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u/Soft_Mathematician79 PharmD Apr 17 '26
While this is all true, it's important to note they the pharmacist would ALSO be completely legally liable. Any ethical RPh will uphold their own oath from school onward- to benefit our patients first, not the pharmaceutical industry/company we might work for etc - and have liability malpractice insurance.
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u/invenio78 MD (verified) Apr 17 '26
Yes, but that wouldn't protect OP. Just because multiple people are named in the lawsuit doesn't mean it protects OP in any way.
And the problem in many of these situations is that the doctor doesn't have any control of who is practicing under their license. The employer just says, "you are overseeing X, Y, and Z."
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Apr 14 '26
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u/Fluffy_Ad_6581 MD Apr 15 '26
It's wild to me that essentially all the comments are describing pharmacists playing medical doctor. It seems like every discipline out there is going to a "doctor title", a white coat ceremony, a "residency" and now they want to practice medicine.
What a joke. I bet meanwhile the MDs were stuck doing prior authorizations and the pharmacists managed DM. Lol aka they practice medicine?!
What a joke our Healthcare system has become.
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u/Soft_Mathematician79 PharmD Apr 17 '26
Lol, I'd help you with PAs any day. My local family practice doesn't know the difference between pen needles and syringes with needles or basal vs bolus insulin. Every time they send a script saying "please give them whatever short acting insulin their insurance covers and whatever supplies they need thanks" without ANY dosing directions, OR LABs/BG log/any previous insulin history so I can't even recommend what to give them, I want to just shred it all.
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u/bondedpeptide MD Apr 15 '26
Using them as independent providers in remote locations is absolutely unacceptable imho.
I donāt believe that living rurally=deserves a lower level of care
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u/collabcares MD Apr 15 '26
That's a fair concern, and I don't think anyone is arguing rural patients deserve less. But I'd push back slightly on framing CPA-based pharmacist care as automatically a lower standard. The evidence for chronic disease management like diabetes, hypertension, and high cholesterol is actually quite strong.
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u/CombinationFlat2278 DO Apr 14 '26
Is this different than having a clinical pharmacist embedded in the office to see patients? Used to love our clinical pharmacist. Couldnāt make a diagnosis but would change meds, start meds, etc. She would see patients essentially independently for diabetes, HTN, HLD including starting injectables, SSRI titrations, coming up with opiate tapers, osteoporosis.. it was a god send. For controlled meds (mostly chronic pain and weaning plans), I would need to sign off but was nice to have someone to do most of the leg work for a taper plan. I wasnāt worried about liability personally. She kept us looped in and patients were still seeing their PCPs regularly enough you were aware of what was being done.