It’s a given that there are healthcare professionals out there with substance abuse problems. But, as we prepare to enter practice, many of us find it difficult to imagine that we’ll be working with affected individuals, or that we could become affected ourselves. Few professional programs ask students to consider what they would do if they suspected or knew that someone in their workplace was impaired. And, still fewer programs formally acquaint students with recovery resources.

No one really knows how widespread substance abuse is within the healthcare professions. With their livelihoods at stake, few people are going to admit to having a problem. Additionally, most health professionals are smart people who are relatively good at hiding their problems. A lecture given by Brian Fingerson, the president of the Kentucky Professionals Recovery Network, indicated that the figure is 12-16% for “pharmacists and some other healthcare professionals”¹.  Given that one out of every nine Americans over the age of twelve was found to have a problem with substance use or dependence in the 2007 National Survey on Drug Use and Health², the suggested range seems quite reasonable.

As healthcare professionals, we may be more likely to develop substance abuse problems than members of the general population due to high work-related stress, increased access to controlled substances, and our knowledge of drug effects. Those of us who do become addicted may be shielded from discovery by the trust of our patients and coworkers. Plus, we may work very hard to avoid discovery, fearing harsh professional, social, financial, and legal consequences.

By this point, it should be clear that you should expect to encounter impaired healthcare professionals during the course of your career. What is less clear is what role you will play in the situation and how you will feel about it.  When you aren’t sure about what is going on, it can be hard to take action. You may only suspect that a coworker is coming to work intoxicated. Maybe there are narcotics missing on a regular basis but you aren’t sure who is taking them. It is reasonable to have fears about accusing an innocent person. You may worry about losing rapport with your coworkers if your suspicions aren’t proven true. There are many other reasons that you may feel compelled not to act. Perhaps you are worried about feeling guilty about turning in a close friend, or taking a provider away from a family. Or, maybe you feel like it’s not your place to take action since others are already aware of the situation.

The bottom line is that an impaired colleague is a danger to both themselves and their patients and needs intervention. If you suspect that a coworker is impaired, you need to connect with someone who can investigate and assess the situation or refer you to resources to do so. This could be your employer, the state board, or a representative from a Professional Recovery Network (PRN) or Caduceus group. If you know that a coworker is impaired, they need to be relieved from duty immediately. But, in order to fully do the right thing, you should also make an effort to connect them the unique support, advocacy, treatment, and recovery resources available through a PRN program. It is may be best to shield yourself by giving the PRN their information and letting the program initiate contact. It is not necessary for the affected individual to know who made the referral.

With the advocacy and monitoring offered by PRN programs, many healthcare professionals are able to regain licensure and return to work while in recovery. These individuals are typically required to sign a contract with the PRN organization and are subject to practice restrictions such as not being allowed to work unsupervised or not being able to work more than a specified number of hours per week.³

While employers or partners must know whether or not a healthcare professional is in a PRN program, coworkers may not.³ They often choose not to identify themselves because they don’t want to deal with the stigma, have their work overly scrutinized, or be judged on a daily basis. If you do discover that a coworker is in a PRN program, I encourage you to be supportive. While there is potential for relapse, PRN programs are used because they work. One pharmacy PRN program coordinator at The Utah Conference on Alcoholism and Other Drug Abuses shared that the drug abuse rates in his state’s PRN program were lower than that of the general pharmacists population. So, with proper monitoring, it may be less risky to hire an individual in a PRN than it would be to hire the average applicant.

For students or professionals interested in learning more about substance abuse in the health professions, I recommend attending the University of Utah’s School on Alcoholism and Other Drug Dependencies, now in it’s 58^th year. This annual week-long event is designed to help students and professionals understand and cope with substance abuse and incorporates a mix of speakers, discussions, social events, and open meetings for recovering addicts and families. Exposure to and interaction with recovering health professionals is one of the most valuable aspects of the program. For students and professionals in recovery the school also offers a unique opportunity to connect with a supportive network of people who share similar experiences. The pharmacy section, which I attended this June, is the largest section of the group, with around 300 participants, mostly students. Other healthcare sections included physicians, dentistry, and nursing. Both college and continuing education credit and are available at a reasonable cost. For more information, please visit http://uuhsc.utah.edu/uas/

1) Fingerson, Brian. “Chemical Dependency Among Healthcare Professionals.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

2) http://www.drugabusestatistics.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch7

3) Quigley, Michael. “Issues in Relapse Prevention and Monitoring.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

When working with a depressed patient the risk of suicide is a very real and present concern. Health care professionals need to be prepared to respond swiftly and effectively. The literature suggests a multi-faceted approach to assess and address the self-harm risk, with one element being the implementation of a “no-harm contract”. The document in its simplest form is a written agreement between the patient and the health care professional that states the patient’s willingness and commitment to notifying a relative or healthcare professional of their intent to harm themselves, instead of engaging in harmful behavior.

No-harm contracts are a common tool utilized in the clinical setting, though there are mixed opinions about their effectiveness, particularly in regard to customized forms. In addition to variation between contracts, many healthcare professionals do not receive any formal training in regard to the proper administration of a no-harm contract, so proper use of the contract may be problematic. It is best for facilities to use a standardized contract so they can train all of the applicable professionals on one document, and have consistency through departments. It is important that professionals make themselves comfortable with the document and can talk about it in-depth if necessary, as being unprepared may suggest that it isn’t important or that you don’t care.

A no-harm contract is an opportunity for a discussion of the importance of the patient’s safety, providing behavioral alternatives to harming themselves, and for the patient to ask clarifying questions or explore concerns about their own safety.

The presence of a healthy therapeutic relationship can provide a safe environment for the patient to share their thoughts and concerns. The no-harm contract is often advocated as an opportunity to build a therapeutic alliance, though some believe the therapeutic alliance must already be present to be efficacious. The professional needs to inquire about the patient’s thoughts about the contract, as some patients may view the contract as an escape behind legalese, rather than a genuine attempt to build a therapeutic alliance.

Things to Keep in Mind When Using a No-Harm Contract

• Having a no-harm contract in addition to other assessment measures and professional follow-up may be the safest course of action for an at-risk patient.

• Patients can vary greatly in educational backgrounds, so it is important to use clearly defined terminology that is comfortable and understandable to the patient, and confirm with the patient throughout that they understand what you are saying.

• A healthy therapeutic relationship can contribute to better compliance, though lack of a therapeutic relationship can have the opposite effect.

• Having an open dialogue can allow input from the patient and health care professional, which may build a ‘buy-in’ for the patient.

• A no-harm contract should not be an automatic response to every situation where there is a possible self-harm risk, as this may diminish the effectiveness of the contract.

• The no-harm contract can be seen as coercive, so it is important to discuss the contract with the patient and let them process their thoughts if needed.

• There is no proven legal safety in solely utilizing a no-harm contract as a means to shield yourself from a lawsuit, so a combination of documented interventions is suggested.

• Be aware that the patient may lull the clinician into lowering safety measures by signing a contract and behaving for a short time, which allows the patient greater opportunity to harm themselves once the restrictions are relaxed.

References

Davidson, M.W., Wagner, W.G., & Range, L.M. (1995). Clinicians’ attitudes toward no-suicide agreements. Suicide and Life-Threatening Behavior. 25 (3), 410-414.

Egan, M.P. (1997). Contracting for safety: A concept analysis. Crisis. 18 (1):17-23.

Kelly, K.T., Knudson, M.P. (2000). Are No-Suicide Contracts Effective in Preventing Suicide in Suicidal Patients Seen by Primary Care Physicians? Archive of Family Medicine. 9:1119-1121.

Kroll, J. (2000). Use of No-Suicide Contracts by Psychiatrists in Minnesota.
American Journal of Psychiatry 157:1684-1686.

Miller MC, Jacobs DG, Gutheil TG. (1998). Talisman or taboo: the controversy of the suicide-prevention contract. Harvard Review of Psychiatry. 6:78-87.

Range, L.M., Campell, C., Kovac, S.H., Marion-Jones, M., Aldridge, H., Kogos, S., & Crump, Y. (2002). No-suicide contracts: An overview and recommendations. Death Studies, 26, 51-74.

Richards, K. & Range, L.M. (2001). Is training in psychology associated with increased responsiveness to suicidality? Death Studies, 25, 265-279.

Stanford, E.J., Goetz, R.R., Bloom, J.D. (1994). The no harm contract in the emergency assessment of suicidal risk. Journal of Clinical Psychiatry. 55, 344-348.

SIEC: Suicide Information & Education Collection. (2002). Centre for Suicide Prevention. Canadian Mental Health Association. 49, 1-2.

For most people, going to the dentist is a nightmare. Whether it is the sound of the drill, the fear of the needle, or just the anxiety of being in the office, they walk in scared and very apprehensive. Most people do not realize that the entire time they are worried about the shriek of the drill or prick of the needle, the dentist carries that same fear but in a different way. Each dentist can only hope that the patients he encounters have been truthful about their entire medical history.

While it is important that the patient choose a clean and reliable dental office, it is twice as important for the dentist to treat every patient as if he has a hazardous disease. This is not meant for the dentist to work in fear, but instead for him to take all the precautions necessary to keep the dental office a safe and clean work environment. Having a dentist that is unaware of the potential hazards in his work environment makes his entire staff, including himself, and his patients more vulnerable to injury.

Dental offices are prime locations for diseases to be transmitted. Many of the procedures involve the use of needles, drills, and other objects that can cause bleeding. A simple extraction leaves much of the office covered in blood, and sometimes even when the blood has dried it still carries different diseases. The remaining, less invasive procedures all require contact with saliva, which also carries many transmittable microbes.

The name of the game in safety is to prevent transmission of saliva-borne and blood-borne pathogens. Whether it is from dentist-to-patient, patient-to-dentist, patient-to-staff, or patient-to-patient, it is crucial that all parties are made aware of the hazards they face. Let this be a guide of the most common pathogens that can be contracted in a dental office. While ignorance is bliss, knowledge is indeed priceless.

Saliva-Borne Pathogens

Although people tend to worry less about things transmitted through saliva, it does not make them any more desirable. Unlike blood-borne pathogens, some people view saliva as only a minor threat, when in reality the little things sometimes add up to the bigger picture. The reality is that most people do not realize how often they encounter someone else’s saliva. People constantly have their fingers in their mouths biting their nails or licking their fingers. Then they touch objects all around them.

Saliva can carry many illnesses, including the common cold, infectious mononucleosis, and cytomegalovirus. There are also other viruses, like herpes, that can also be transmitted through saliva. Many cold sores are the result of the herpes virus. Herpes results in blisters that can form on the mouth, lips or genitals. These blisters may also recur periodically in place of ones that disappear. Herpes can also leave unwanted scarring and can be quite painful.

Other things like Methicillin-Resistant Staphylococcus Aureus (MRSA) can be transmitted. It may not be a huge threat for those that have a healthy immune system, but those that have an immune deficiency are at great risk. Symptoms of MRSA include skin infections that resemble a boil or an abscess. The area is often red, swollen, painful and filled with pus. MRSA can also present other symptoms since it can affect the urinary tract and the bloodstream. If Staph. affects the lungs and causes pneumonia, you can also have other symptoms such as shortness of breath, fever, and chills.

Blood-Borne Pathogens

In comparison to saliva-borne pathogens, blood-borne pathogens are more serious. Blood-borne pathogens may seem difficult to contract, but in actuality the hazards are everywhere. They can be transmitted through accidental punctures from contaminated needles, broken glass, or other sharp objects around the office. Contact between broken or damaged skin and infected body fluids will also transmit any blood-borne pathogen. This is a list of the most common pathogens and some of the risks they carry.

Hepatitis B (HBV) is primarily transmitted through “blood to blood” contact. HBV initially causes inflammation of the liver, but with time can also lead to more serious conditions such as liver cancer and cirrhosis. HBV cannot be cured, but can be treated to help people build antibodies to fight an infection and keep it from returning. There are vaccines that can be administered to prevent contraction of HBV. HBV is very durable and can survive in dried blood for up to seven days, so any blood around an office should be handled with extreme care. Symptoms of HBV include nausea, fatigue, possible stomach pain, loss of appetite, jaundice and darkened urine. Those infected may not show signs for up to nine months.

Hepatitis C (HCV), similar to HBV, also affects the liver. Hepatitis C damages the liver and can be very tricky because it does not always show immediate symptoms. Around 80% of people diagnosed with hepatitis C see no symptoms. If symptoms do emerge, it usually takes 10-20 years, sometimes even longer. This asymptomatic latency can cause serious damage. Hepatitis C is also transmitted in a similar manner as HBV, from blood-to-blood contact. Symptoms of hepatitis C are very similar to those of HBV, and it also has no cure. Considering hepatitis C targets the liver, the body is at a greater risk of infection, prolonged bleeding, and inability to break down toxins.

Human Immunodeficiency Virus (HIV) attacks the body’s immune system and weakens its ability to fight diseases. HIV can develop into Acquired Immune Deficiency Syndrome (AIDS) over time. HIV, which has no cure, can be fatal. Even though it is said that there is a 0.4% risk of contracting HIV in the workplace, this disease is deadly and every precaution should be taken. Symptoms of HIV include weakness, sore throat, fever, headaches, diarrhea, nausea, weight loss, a white coating on the tongue, and swollen lymph glands.

This information is not meant to frighten, but instead to prepare healthcare providers. When entering a healthcare profession, we are made aware of the risks, but it’s easy to forget them. You can never get too comfortable or be too careful. Life is precious and as healthcare providers, we should be the ones to set the example and inform those that may not carry the same knowledge.

References:

EHS Safety Training Bloodborne Pathogens. http://www.pp.okstate.edu/ehs/modules/bbp/index.htm

Seroquel, with its connotations of well-being and peace, sounds like the name of a bird or a midlevel car. It doesn’t sound like something that causes weight gain or blurred vision while treating psychosis, nor does it sound like something associated with financial strife. The pills, tiny, white and innocuous, don’t LOOK expensive. But at nearly $600 for a month’s supply, the cost easily exceeds rent for many people.

When I started the drug, I dutifully paid the $30 co-pay and let my insurance company handle the bulk of the cost. What I didn’t realize was that each month, behind this co-pay, the insurance company received a bill for $595.00, whittled down to a “negotiated rate” of $498. While I took for granted that my insurance company shouldered the burden of my monthly costs, both for Seroquel and several other psychotropic drugs, I didn’t realize that the benefit had an annual cap of $2,500.

I came to this realization a few months into my policy year when my pharmacy bill, usually under $200, mysteriously quadrupled. After leaving the pharmacy in tears, minus my drugs, I called my doctor to bewail this misfortune. I called my father to ask for money, and I started an Internet search for solutions. I’d heard about Canadian pharmacies and cheap drugs, so I focused my efforts there.

A Google search for key words Canadian Pharmacy yielded over 8 million results with just about every iteration of the words Canada, Pharmacy, Drugs, and Prescription. The pharmacies boasted “discounts of up to 70%,” “easy ordering,” “legality,” and they featured pictures of smiling, care-free gray-haired seniors.

Eager to take advantage of “savings up to 70%,” I went to one of the web sites where Seroquel, sold as generic quetiapine, was available for $99.00. Before completing the purchase, I had to fill out my primary physician’s name, phone number, medication list. I had to answer a series of yes-no questions about whether I was a smoker, had arthritic disorders, glaucoma, etc. I sent my prescription with payment and received my 90-day supply of quetiapine.

The legality of the importation of such drugs is called into question by the federal Food and Drug Administration. Any drug manufactured in the United States cannot legally be imported from another country (21 U.S.C. § 381(d)(1)). Also, any drug not approved by the FDA (21 U.S.C. 331(d) 355(a)), nor any incorrectly labeled drug may be imported (21 U.S.C. § 353(b)(2)). http://www.fda.gov/ora/import/kullman.htm. It is, however, legal to import drugs which are approved by the FDA, not manufactured within the U.S., and which bear correct labeling. There is a stipulation making legal the import of experimental treatments of serious diseases given that these treatments do not pose a serious risk. http://www.fda.gov/ora/import/traveler_alert.htm

Most drug companies do offer aid to individuals unable to afford prescriptions. Generally, patients must submit an application to the necessary drug company explaining their lack of income, insurance, savings, and just about any other means to pay for drugs.

Any denied claims may be appealed, accompanied by a detailed letter describing the inadequacy of the insurance, income, and savings in the face of mounting health care bills. Those who are poor and adequately persistent may be supplied with free drugs.

Finally, drug samples often are used to satiate patients. While organizations such as No Free Lunch condemn the use of lavish dinners, pens, samples, and any number of ploys meant to influence physicians, these items are heralded as useful to those who cannot afford dinners, those who need pens, and patients who cannot afford their drugs. Samples are not intended for use by those unable to afford drugs, although this does happen.

During my own quest for affordable medications, I broke federal laws, I groveled, and I misused drug samples. Due to the obvious stigma associated with my desired pills, I found myself additionally handicapped. If I’d been attempting to eradicate pimples, erectile dysfunction, or joint pain, I would have felt more comfortable asking for advice and help — or, at least, moral support. But I worried that if I spoke of MY problems, I’d field questions about the exact nature of my illness, the specific drugs involved, etc.

I’ve managed to convince AstraZeneca and other drug companies that I qualify for their charity programs. I have a steady supply of free, legal drugs. And, more importantly, I’m aware of some of the obstacles future patients of mine may face. Even though I don’t plan to become a psychiatrist, I’m more aware of the needs and potential problems patients suffering from any chronic medical problem.

Dr. Robert M. Wachter, a professor of medicine, chief of the medical service and chair of the patient safety committee at UCSF Medical Center, has been a central figure in educating the medical community and general public about pressing safety issues in healthcare institutions. Dr. Wachter has written prolifically on this topic, including the bestseller Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. He has discussed patient safety on CNN, NPR, and ABC’s Good Morning America, and been quoted in the New York Times, the Wall Street Journal, and Time, to name only a few. His new textbook, Understanding Patient Safety, will be published by McGraw-Hill in October 2007. Here, Dr. Wachter discusses the world of patient safety and healthcare.

What prompted you to write your book, Understanding Patient Safety, at this point in time?
I get asked all the time – by medical and nursing students, senior hospital administrators and board members, quality and risk managers – to recommend a lively, engaging and evidence-based introduction to the field of patient safety written with a clinical slant. I couldn’t find a book that fit the bill, so the time seemed right to write one.

What has had the biggest impact on patient safety in the last 5 years?
The first step was awareness. Beginning with the publication of the Institute of Medicine report on medical errors in 2000, we now recognize how serious the problem of medical errors is – how many people are harmed and killed each year from medical mistakes. We also have discovered that our old approach to errors – just try to be really, really careful – was hopelessly flawed. So I think the combination of increased attention and a new approach, known as “systems thinking,” has made the largest difference.

What is the most common medical error occurring in healthcare institutions today?
Most errors relate to poor communication, between doctors and other doctors, between doctors and patients, between nurses and pharmacists, you name it. These communication glitches result in medication errors, surgical errors, radiology errors, and more.

Have advances in medical technology helped to minimize or increase the number of medical mistakes?
Both. On the one hand, technology is helping to decrease errors, such as through the use of computerized medical records, computerized order entry, and bar coding. Even relatively simple technologies that we don’t think of as “safety” oriented – text paging, portable ultrasound for catheter insertion or drainage of fluid from the abdomen or thorax – are actually saving lives. On the other hand, technology has made medicine much more complex, and therefore created many new errors. MRI scans are spectacular, but we didn’t have to worry about tanks of oxygen being converted into potentially fatal projectiles before we had scanners with powerful magnets.

In your opinion, what is the most important step hospitalists can take to address patient safety?
After I coined the term “hospitalist” in a 1996 article, I worried that the field was becoming known as being largely focused on efficiency – cutting hospital length of stay and costs. I’m quite proud that the last decade has seen an increasing focus by hospitalists on patient safety and healthcare quality. Hospitalists have to serve as the orchestra conductors for sick inpatients, pulling all the information together to provide the highest quality, safest care. And then they have to focus like a laser on ensuring that there is no information “voltage drop” at the time of discharge.

What future trends do you see emerging in the realm of patient safety and medical errors?
Computerization has clearly reached the tipping point – within a decade, it will be very unusual to find a hospital or large doctors’ office that still relies on pen and paper. We’re finding that IT improves safety in many ways, but that we’ve introduced a whole slew of unanticipated consequences, including some new classes of errors. The recognition of the critical importance of culture in safety is another major trend, with lots of effort going into trying to improve teamwork and collaboration. Simulation is beginning to take off. More attention is being paid to the importance of a well rested, well trained workforce. The residency duty hour limits of 80 hours a week are only the start. And the increased public attention to medical errors is leading to much more public reporting. There are truly 1,000 flowers blooming when it comes to safety.
What can Program Directors do to enhance residents’ attention to issues of safety and quality?
As a former residency program director, I had my residents partly in mind when I wrote Understanding Patient Safety. I find that residents are incredibly interested in patient safety, and they appreciate being taught it in a case-based and engaging way. They are also great at coming up with solutions. Go into any teaching hospital and try to figure out which systems need improving. All you need to do is ask the residents and the nurses and you’re done. The trick is to give them the opportunities to tell us, and then the skills to help be part of the solution.

What does ACGME expect and look for in terms of patient safety and health quality?
There are new mandates, from ACGME and some of the certifying boards, for residents to become competent in systems-based approaches, such as those in patient safety. But institutions and programs are still trying to figure out how to teach this material to residents in ways that engage them and stick. I hope this book can be one helpful tool.

How are the specialty boards handling the issue of patient safety? Are we seeing more cases and questions related to the topic?
Yes, it is all of a piece – the accreditors of medical and nursing schools, of residencies, and of practicing specialties have all recognized how critical patient safety is, and are using all their levers to promote a deeper understanding of the topic among their stakeholders. We’ll see more and more questions on every type of certifying exam on issues of safety and quality.

Almost 1,000 medical students from over 90 different countries gathered in Canterbury this August to tackle inequities in health care across the globe. The 56th August Meeting of the International Federation of Medical Students Associations returned to the UK with the theme, “Access to Essential Medicines.” It proved to be a fascinating, tumultuous, and at times controversial week.

The IFMSA is the largest student body in the world, founded in 1952 to provide a cohesive voice for medical students across the globe. Its biannual general assemblies aim to educate and inspire its members to take action on international health issues, each centered around a chosen theme. The decision by the UK to focus on “Access to Essential Medicines” (AEM) was taken in light of its key relevance to both the developed and developing worlds. More than 10 million deaths each year can be attributed to lack of access to life-giving medications, in direct contravention of the Universal Declaration of Human Rights, entitling every citizen the right to “health and well-being of himself and his family, including … medical care and necessary social services”.  

The Assembly was opened, with customary vigor, by Dr. Richard Horton, chief editor of the Lancet. He spoke of the “collective failure” of medical institutions to produce doctors engaged with society, both domestically and globally. Increasing inequality in access to health care, he argued, demands that the moral contract between the medical profession and society be rewritten such that doctors come to see the assertion of justice as a fundamental part of their duty. It requires that doctors and medical students are prepared constantly to “disagree and quarrel with, object to, dissent from and disapprove of, resist, disbelieve, refuse, oppose, challenge, contradict and defy (their) governments” as and when the need arises. Justice in health, he concluded, should be paramount to all medical practice: “The social pathology of globalization, inequity and epidemic human misery that we face today demands nothing less.”

The spirit of revolt continued throughout seven days with a series of lively debates, speeches and seminars from experts as diverse as Hans Hogerzeil (director of Department of Medicines Policy and Standards, WHO), Parveen Kumar (chairman of the BMA), Richard Smith (CEO of United Health Europe and former editor of BMJ) and Richard Barker (chairman of Association of British Pharmaceutical Industries).

Informal lunchtime sessions on “Systems,” “Activism” and “How Students Relate to the Pharma Industry” encouraged students to take a personal stand. Videos on AEM ran throughout the week and computer-assisted learning packages provided real and well-argued evidence to back the rhetoric. Representatives from a range of non-governmental organizations, including Medecins Sans Frontieres and Oxfam, attended, tirelessly explaining their work and encouraging hundreds of medical students to consider work overseas. For, as Prof. John Yudkin (former director of the International Health Medical Education Centre) observes in the AEM film, “It is not just about access to drugs, it is about access to people who can prescribe and safely deliver those drugs.”

Record numbers of travel bursaries to the UK were distributed to students from economically-less developed countries who would have been otherwise unable to attend the Assembly. The sheer number and diversity of students encouraged a variety of viewpoints, and debates could be heard echoing through the corridors long after the speakers had finished. Projects and campaigns were coordinated from opposite sides of the world and many exchange schemes initiated.

The week culminated in the creation of “The Canterbury Declaration” and its formal adoption by the IFMSA. The Declaration supports the WHO Access Framework and, while recognizing the need for trade-related intellectual property rights legislation, advocates for countries making full use of its flexibilities. Importantly, its adoption lends the IFMSA a clear and consistent voice on the matter of “Access to Essential Medicines.” The Declaration encourages student protest and pledges support to all campaigns aimed at increasing governmental spending on AEM, challenging cases where essential medicines are priced beyond the reach of the poor and promoting transparency within the pharmaceutical industry.

The voice of the IFMSA is a powerful one and has in the past informed both national and, through its affiliation with the World Health Organisation, international policy. Its work is mainly directed into five main areas, recognised as peripheral to core medical curricula but central to the reality of health care. These are reproductive health (including AIDS), human rights and peace, public health, professional and research exchange, and medical education.

The UK branch of the IFMSA, Medsin-UK, is especially active and has branches in 28 different medical schools across the country, involving hundreds of health care students in its projects, campaigns and educational events. Its network aims to connect innovative projects and enthusiastic students to work together in addressing the broader determinants of health.

If you would like to know more about the IFMSA or Medsin-UK, or to get involved in the campaign for Access to Essential Medicines please see www.ifmsa.org or www.medsin.org

The issue is often framed as a question of patient rights vs. pharmacist rights, due to the public controversy over the emergency contraceptive “Plan B” which has unfolded over the past decade. However, the issue carries broader implications, extending to drugs intended for abortion or immediate post-abortion care, lethal injection for use in the potentially abused medications such as narcotics.

The stakes are so high for interested parties that states across the country have been pressured to take a position for or against pharmacists’ refusal to fill through legislation and policy changes. As of November 2006, five states (AR, CA, GA, MS, SD) have chosen to codify the right of a pharmacist to refuse to fill a prescription on moral grounds, while four (IL, MA, NC, PA) have passed legislation requiring pharmacists to fill or transfer certain prescriptions.¹

On March 23, 2007, Washington became the 5th state to take a stance against refusal to fill when their Board of Pharmacy amended policy to require that pharmacists make a good faith effort to fill any legal and medically appropriate prescription.² At the same time, the Board set standards defining and mandating professional behavior in cases when declining to fill is unavoidable. Specifically, pharmacists may not destroy or refuse to return a lawful prescription, violate patient privacy or rights under federal anti-discrimination laws, or intimidate or harass a patient.

Some states’ laws are broad in scope, applying to all medications, while others apply only to certain controversial prescriptions. Unfortunately, in each of the states mentioned above one group loses out, with the needs of either patients or objecting providers remaining entirely unaddressed.

For patients wishing to fill a controversial medication, the inability to access a willing healthcare provider is a barrier to care. Sometimes that barrier can be overcome by simply seeking out an alternate care provider. In other cases, no alternate is available. Some patients may be unable to access an alternate due to personal limitations such as transportation, insurance coverage, finances, prior time commitment to an employer, or lack of knowledge about where and how to access alternate care.

As with emergency contraception or pain medication, timely access to medication may be crucial, so a temporary delay may be undesirable, despite the presence of other accessible medication providers. Regardless of the feasibility of seeking care elsewhere, many patients are simply upset that a third party would have the power to refuse to fill a valid prescription when they have a legitimate medical need.

Often, refusal to fill is an issue of professional discretion, basic moral freedom, or practice of religion. Some practitioners feel that they should be able to decline any prescription for any reason because imposition of any limitations would impinge upon their professional discretion. This is a legitimate concern, as even legally written controversial medications may be inappropriate due to medical contraindications.

Others feel that because their license is on the line every time they fill a prescription they should be the one to decide when not to fill a medication. Independent pharmacy owners and those who have chosen to practice in religiously affiliated healthcare systems may be especially adamant about the right to determine their own scope of pharmacy practice, limiting it to those items which they can dispense in good conscience.

A mandate to participate would harm some practitioners, forcing them to choose between religious or moral convictions and their perceived professional duties. Where religious freedoms are denied, such legal statutes may be unconstitutional. Ironically, such laws could make lawbreakers out of otherwise good practitioners who refuse to stand down on the issue. The situation is especially frustrating for providers with religious or moral objections, as many entered the profession before the advent of controversial medication such as emergency contraception and are now confronted by a dilemma they could not have foreseen.

While some pharmacists are adamant about the right to refuse to fill a legally written prescription on moral grounds, there is no consensus on the issue within the profession. Many pharmacists disapprove of refusing to fill a prescription on moral grounds, citing that it is an unprofessional imposition of one’s personal morality on the patient. A handful believe that this offense is egregious enough to warrant dismissal from the profession.

Others support the right of a pharmacist to refuse to fill so long as the patient is able to obtain the medication elsewhere. It may be considered essential that the medication be provided by someone on-site, or acceptable to refer the patient to a provider at a different location.

To further complicate matters, individual pharmacists may be willing to accept some moral objections, but not others. For example, most pharmacists consider it not only acceptable but morally responsible to decline early refills on narcotic medication. For no definable reason, others may be willing to accept religious objections when it comes to abortifacients, but not when it comes to the emergency contraceptive, Plan B. The only uniting thought seems to be disgust and frustration at the negative media attention brought on the profession by the refusal to fill issue.

Refusal to fill will continue to be an issue until controversial medications are readily available to those who seek them. To those who see refusal to fill legislation as an easy fix – on either side of the dilemma – I submit that it is no fix at all. Only by making an abundance of willing providers available to the public can we truly eliminate this dilemma.

Instead of berating those who do not feel comfortable dispensing controversial medications, we should be working to improve the number of access points. Prescribers of known controversial medications can help improve patient access by suggesting to their patients at least one pharmacy that is known to stock and dispense the prescribed medication. If no local dispensing sites are known, in-office dispensing should be considered.

Pharmacists can help by making themselves known to key providers as dispensers of controversial medications and by placing themselves on provider lists where they exist, such as the national Plan B registry administered by Princeton University.³ Development of local provider registries by public health departments or public minded healthcare providers can also promote access to controversial medications.

Those of us who gladly dispense controversial medications need to step up and announce our presence. Only when the public knows who we are and how to access our services will the controversy be over.

References

1) Hopkins, Denise and Marsha Boss. “Pharmacists Right to Refuse to Dispense
Prescriptions Based on Moral Grounds: A Summary of State Laws and
Regulation.” Hospital Pharmacy. 41 (2006): 1176-1179.

2) “Professional Responsibilities of Pharmacists & Pharmacies.” WAC 246-863-095,246-
869-010. 2007. Washington State Board of Pharmacy. 27 February 2007.

3) Office of Population Research. “Emergency Contraception” 2007. Princeton
University. 4 April 2007.

While handwriting doesn’t play a major role in most peoples’ careers, in the medical field, it can mean the difference between life and death. Whether it’s a mix-up between Lamisil and Lamictal, Cerebyx and Celebrex, Zyrtec and Zantac, or Sarafem and Serophene, confusion over drugs with similar spellings and similar sounds accounted for 15 percent of all errors reported to the United States Pharmacopeia Medication Errors Reporting Program from 1996 to 2001. In fact, it’s such a problem that the Food and Drug Administration even appointed a panel of experts to review proprietary drug names—just to try to alleviate such confusion in the future.

But beyond drug name mix-ups, poor penmanship also accounts for many other errors. From 1993 to 1998, a total of 52 deaths resulting from drug name errors were reported. And according to the Institute for Safe Medical Practices (ISMP), in the year 2000, indecipherable or unclear prescriptions resulted in more than 150 million calls from pharmacists to physicians asking for clarification—a time-consuming process that could delay important treatments, as well as lead to injury or even death.

These mistakes could also cost those involved. In 1999 in Texas, a jury awarded a woman $450,000 because her husband died from taking the wrong medication due to his doctor’s poor penmanship and the pharmacist mistakenly giving him the incorrect medication as a result.

“Reading prescriber handwriting is an acquired art,” explains Anna Peck, who is both a pharmacy student and worker. “Much of the ability to decipher prescriptions comes from pre-exiting knowledge of drug names and sig (shorthand) codes. Someone who practices in a retail setting may not be able to read messy hospital orders and vice versa.”

Peck says that last year, her state legislature (Wash.) passed legislation stating that cursive prescriptions are deemed illegible and must be verified by phone or fax, or simply rewritten.

“In the two weeks between the passage of the law and when word came around that the Board of Pharmacy was not enforcing it, I learned that forcing prescribers to write in block letters does not make crappy handwriting any better,” she added. “In fact, cursive is usually easier to read.”

At Cedars-Sinai Medical Center, the powers that be have offered special classes in handwriting for members of their medical staff. After contacting a firm that specialized in teaching people good penmanship, nurses and administrative staff were asked to help identify physicians who would most benefit from the class. The three-hour course was self-instructional and emphasized a cursive italic handwriting style, with tips on the correct position of the paper, the size of letters, the length of strokes, and how to hold the writing instrument.

Beyond penmanship pointers, the ISMP advocates the use of electronic prescribing tools that computerize the process of ordering prescriptions, which has been shown to reduce potentially harmful prescription errors, allergic drug reactions and excessive drug dosages. These computers also check for drug side effects, drug interactions and inappropriate dosages, among other errors.

But if a physician is planning to stick with pad and pen, experts recommend using caution when writing prescriptions or orders for drug products with brand names similar to other brand named drug products, generic names similar to other generic named products, or brand names similar to other generic named products.

While Peck has heard of one guy in Everett, Wash., whose handwriting was so bad that the state board restricted his prescriptive authority to typewritten or electronically generated prescriptions, she says, “Honestly, most of the prescriptions we get are ultimately legible, even if they appear messy.”

“I’d venture to guess that quite a few more mis-fills are blamed on ‘illegibility’ than are actually caused by it. Often, bad handwriting is used as an excuse for sloppy eyesight or other errors. A truly illegible prescription usually cannot be read at all and the prescriber must be contacted for clarification. Only rarely do we find that we truly misread one drug as another, one dose as another, or one sig as another, because the item was really ambiguous and that fact eluded us.”

We present this article to highlight the debate currently in progress over use of animal labs in student education. SDN has no formal or informal position on animal labs. Our volunteer members have a diverse view on this topic and have worked together in an attempt to cover this topic fairly and evenly.

Jeff Tomasini likes dogs. That was one of the reasons that prompted the first-year student at the Medical College of Wisconsin (MCW) to opt out of a course he considers barbaric and unnecessary. During the three-day class that took place last month, Jeff’s classmates anesthetized 60 dogs obtained from the local pounds, opened up their chest cavities, examined their hearts, and then euthanized the animals.

“Killing an innocent animal is unethical,” Jeff says. “The top medical schools produce some of the country’s best physicians without ever harming an animal.”

And he is not the only one to protest the course that is fueling heated debates among students, physicians, and medical school educators across the country: do live animal labs have educational merit for medical students, or are they relics of the past?

At the center of the polemic is MCW’s physiology class that gives first-year students a rare opportunity to see a live, beating heart. MCW is currently one of only 14 medical schools in the United States offering a live animal lab.

Opponents of animal labs argue that technology – such as the widely used, life-like human patient simulators – eliminate the need to experiment on live animals. Proponents insist that such methods are effective teaching tools, especially since a dog’s cardiovascular system resembles that of a human.

“Computers cannot replicate the complexity of living systems,” Richard Katschke, Associate Vice President of Public Affairs at MCW told SDN. “Physiology, by definition, is the study of living systems. The live animal lab enables students to draw on the knowledge they have learned to date, and apply the information in a real-life situation. In student course evaluations, this lab receives higher ratings than any other course for first-year medical students.”

Indeed, in Jeff’s class of 204 students, only 12 opted out of the dog lab. And a few months ago three students wrote an editorial for their local paper, the Milwaukee Journal Sentinel, praising the course. “Based on our experience with this lab, the majority of our classmates agree that placing one’s hands on a beating heart, seeing live lungs inspire and expire, and seeing textbook knowledge literally come alive is an invaluable experience,” they wrote in an article endorsed by over 100 MCW students. “Our professors believe this teaching laboratory will make us better doctors, and of this we have no doubt.”

On the other side of the debate are organizations such as the Physicians Committee for Responsible Medicine (PCRM), a Washington D.C.-based group that promotes non-animal educational alternatives. PCRM has been criticized by consumer and professional watchdog groups, including the Center for Consumer Freedom, as being a “fanatical animal rights group” and serving as a front group for the People for the Ethical Treatment of Animals (PETA).

“Using live dogs is a pitifully inadequate way to teach,” says John J. Pippin, Senior Medical and Research Adviser at PCRM. “Are students likely to encounter an open-chest dog in the clinics or their practices of medicine?”

He questions MCW students’ contention that seeing live organs in an anesthsized animal is an educational experience. “The students get one shot at the dog, can test at most a few drugs, can only see responses under the rigid and unnatural conditions of anesthesia and intubation, occasionally kill their animal or watch him die before they are finished, [and] get no do-overs after the animal is dead.” Pippin also questions the ability of inexperienced students to assess the usefulness this course would have for their future careers.

The American Physiological Society (APS), a Bethesda, MD-based organization for science and medicine professionals, disagrees. “This is a matter of educational quality,” Dr. Martin Frank, the APS Executive Director says in a published statement. “Students benefit from the hands-on learning approach that animal laboratories offer.”

That comment is echoed by many of the nation’s physiologists who see substantial educational merit in live animal labs. “These laboratories have provided medical students with an opportunity to directly observe the physiology, anatomy and response of both internal and external environmental stimuli on a live organism that responds in an identical or very similar fashion to the human,” James E. Smith, Professor and Chairman of Physiology and Pharmacology at Wake Forest University School of Medicine is quoted on MCW’s website. “This is an invaluable educational opportunity that too many medical schools have abandoned.”

That position is endorsed on MCW’s website by several other physiologists from various medical schools, who say live animals provide experience and insight that other teaching methods do not.

“Physiologists and their professional organizations have a strong self-interest in preserving the use of live animals, because it’s what they know and sometimes one of the main reasons they are on faculty,” Pippin counters. “Live animal physiology may have applications to study comparative physiology or a particular animal’s systems, or for individual physiologists’ research interests, but not for students training to be medical doctors rather than physiologists.”

Rooshin Dalal, a student at University of Virginia School of Medicine, and a vocal opponent of animal labs, points out that “the argument about animal labs allowing students to touch living tissues is baseless. All of the same demonstrations can be easily observed in the human operating room – with the important advantage of learning about human anatomy and physiology – and surgeons will likely allow students in their third and fourth years to handle living tissue as well,” he says. “And, if there were some benefit to animal labs, wouldn’t most schools be using them?”

Currently 111 allopathic medical colleges in the United States no longer maintain animal labs. Pippin states that an ongoing PCRM survey, which includes top universities such as Pennsylvania, Mt. Sinai and Cornell, shows that replacing animals with simulation technology has had no adverse effect on curriculum or student performance.

“These (simulation) tools are so much better than using animals,” says one of the responders to the survey, Martin Eason M.D., J.D., director of the Patient Simulation Laboratory at East Tennessee State University Quillen School of Medicine. “No school should be depriving their students of them.”

In fact, most schools don’t. According to American Association of Medical Colleges, simulation and other technologies are now being used by 79 percent of U.S. medical colleges. MCW has top-of-the-line simulators as well, but offers the dog lab as an optional course.

Supporters of eliminating live animal experimentation scored one victory last week, when the American Medical Student Association (AMSA) passed a resolution encouraging the replacement of live animal laboratories with non-animal alternatives. The 65,000-member umbrella organization for premedical and medical students, interns, and residents also condemned the use of household pets from pounds, shelters, or random source dealers, thus reversing its earlier position, which endorsed pound seizures.