Original Research
Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

Previous Presentations: This study was presented previously at the American Pharmacists Association Annual Meeting, March 18, 2007, Atlanta, Georgia, and at the 2007 Eastern States Pharmacy Residency Conference, May 11, 2007, Baltimore, Maryland.
https://doi.org/10.1016/j.sapharm.2009.11.008Get rights and content

Abstract

Background

Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.

Objective

To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.

Methods

A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.

Results

On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.

Conclusions

The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

Introduction

The recent proliferation of medication therapy management (MTM) services offered through Medicare Part D1, 2 has put a spotlight on patient care opportunities for pharmacists, particularly those who practice in the community setting. Activities, such as community pharmacist-provided MTM and disease state management, are enhanced when an effective collaborative working relationship (CWR) exists between the pharmacist and the patient's physicians. The potential benefits of physicians and pharmacists working together have been documented.3, 4, 5, 6, 7 Nevertheless, community pharmacists struggle to establish relationships with physicians. Lounsbery et al surveyed 970 pharmacists from various outpatient practice settings regarding their agreement with potential barriers in providing MTM services and found that community pharmacists were more likely than pharmacists in other ambulatory settings to agree that establishing CWRs with physicians was a barrier to service provision.8

To assist practitioners and researchers interested in pharmacist collaborations, McDonough and Doucette have proposed a conceptual model for the development of pharmacist-physician CWRs (Fig. 1).9 The CWR model was synthesized from models of interpersonal relationships, business relationships, and collaborative care from nursing/physician relationships.10, 11, 12, 13, 14, 15 This framework illustrates how individual, context, and exchange characteristics influence movement along a collaboration continuum, from stage 0 (professional awareness) to stage 4 (commitment to the CWR).9 Individual characteristics are those specific to each collaborating professional, such as age and educational background. Context characteristics, such as the proximity of the professionals and shared organizational structures, are associated with the practice site of the collaborators. Exchanges are the personal interactions that occur between physicians and pharmacists.

Using the CWR model as a guide, Zillich et al demonstrated that, although select participant and contextual characteristics influenced relationship development, exchange characteristics are the principal drivers in the development of pharmacist-physician collaborations.16 In 2005, Zillich et al found that these exchanges can be grouped into 3 domains: relationship initiation, trustworthiness, and role specification.17 The extent of professional collaboration can be quantified through the administration of the Pharmacist-Physician Collaborative Index (PPCI), a 14-item Likert scale that measures collaboration within the 3 exchange domains.16, 17, 18 This quantitative measure, however, does not reveal the specific exchanges that have occurred to reach a high level of collaboration.

The purpose of the present study was to describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using the aforementioned conceptual model and tool for quantifying the extent of collaboration among the professionals as guides. Insights from this study may assist researchers interested in understanding collaborative care models and pharmacists interested in developing collaborations in their practice, while further validating the CWR model proposed by McDonough and Doucette.9 To the authors' knowledge, this is the first study to explore, quantitatively and qualitatively, the professional exchanges occurring among pairs of community pharmacists and physicians engaged in highly CWRs.

Section snippets

Study design and participant recruitment

The first step in studying the professional exchanges occurring among highly collaborative pharmacist-physician pairs is to identify examples of these pairs to serve as research participants. In qualitative research, participants are selected for their familiarity with the concept in question19—in this example, the professional exchanges that have led to successful collaborations. Therefore, a nonrandom, purposeful sampling technique was used for participant identification and recruitment.19 In

Sample

There were 87 identified pharmacists representing a minimum of 29 states and Puerto Rico. Of these identified pharmacists, 24 provided consent and completed the online survey tools. Ten of these pharmacists were excluded, because they did not practice in a traditional community setting. Two pharmacists were excluded for incorrectly completing the survey tools (eg, not providing the name of a physician colleague). Two pharmacists did not respond to the request for participation in the

Discussion

The process for identifying community pharmacist-physician pairs engaged in effective CWRs was fruitful. Despite not providing experts with a clear case definition of “effective” or “successful,” the pharmacist PPCI scores were comparable with the highest scores reported in earlier studies, indicating high levels of collaboration among the identified sample.18 In addition, the physicians' PPCI scores were higher across each domain compared with previously reported scores among a large,

Limitations

This study had a relatively low response rate; 26% of the “experts” responded to the request for pharmacist identification, and fewer physicians than pharmacists agreed to participate in the online surveys and interviews. This may be because of “expert” misinterpretation of study-inclusion criteria. For example, the first author received several e-mails from “experts” stating that they could not identify a pharmacist, because the state they reside in does not allow legal collaborative practice

Conclusion

The study findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. It was observed that relationships appeared to develop in a manner consistent with the CWR model, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on

Acknowledgments

The authors would like to acknowledge Brittany DeVoge, Pharm.D., Gladys Garcia, Pharm.D., and Cheri Hill for assistance with data collection and management; Lois Edmondston for assistance with tables and figures; and the American Pharmacists Association Foundation and the Community Pharmacy Foundation for grant support.

References (21)

There are more references available in the full text version of this article.

Cited by (119)

  • Pharmacists’ intention to prescribe under new legislation

    2022, Research in Social and Administrative Pharmacy
  • Best practices in mixed methods for pharmacy and health services research

    2022, Contemporary Research Methods in Pharmacy and Health Services
View all citing articles on Scopus

Financial Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employments, gifts, stock, holdings, or honoraria.

Funding: This study was supported by the American Pharmacists Association Foundation and the Community Pharmacy Foundation. Also, Dr. Zillich was supported by a Research Career Development grant from the Veterans' Affairs Health Services Research and Development (#RCD 06-304-1).

1

At the time of this research, Dr Snyder was Community Practice Resident at the University of Pittsburgh School of Pharmacy, and Ms. Rice was M.P.H. Candidate at the University of Pittsburgh Graduate School of Public Health and Research Associate, University of Pittsburgh School of Pharmacy.

View full text