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EDITORIAL

Nos injerimos?
Are we meddling?
esde febrero de 1998 la Organizacin ince Februar y 1998 the Spanish Medical

D S
Mdica Colegial (OMC) viene planteando Association has posed the accusation of "pro-
la acusacin de "injerencia profesional" fessional meddling" with respect to
respecto de la prctica de la Atencin Pharmaceutical Care which from this journal
Farmacutica que desde esta revista y and Foundation we are trying to encourage.
esta Fundacin tratamos de impulsar. On March 27th 2000, this Association emit-
Con fecha 27 de marzo de 2000, la ted to all medical associate members in Spain
OMC ha difundido a todos los colegiados two documents, the first of which titled "The
mdicos de Espaa dos documentos, el limits of physicians' and pharmacists' professio-
primero de los cuales titula "Lmites de nal functions"; established the limits of our pro-
las funciones profesionales de mdicos y farmacuti- fessional competence in a unilateral way, with no pre-
cos"; en el mismo se establecen los lmites de nues- vious agreement with any entity representative of the
tras competencias profesionales de forma unilateral, pharmacists. The document questions our professional
sin acuerdo previo con ninguna entidad representa- competence to be able to go further than the mere
tiva de los farmacuticos. El documento pone en dispensation of medicines in our custody. This
cuestin que nuestras competencias profesionales Association is worried about the legal indefinition of
puedan ir ms all de la mera dispensacin de los the Law of April 26th 1997 of regulation of community
medicamentos por nosotros custodiados. A la OMC pharmacy services, which according to their judgement
le inquieta la indefinicin legal de la Ley de 26 de facilitates the "interference of the pharmaceutical pro-
abril de 1997 sobre Regulacin de Servicios de las fession in the assistential terrain of the physician".
Oficinas de Farmacia que, a su juicio, facilita la "intro- On the other hand, examples of simulated cases in
misin de la profesin farmacutica en el terreno some Pharmaceutical Care distance courses, with the
asistencial del mdico". object of teaching pharmacology and pharmacothe-
Por otra par te, ejemplos de casos simulados utili- rapy have occasioned that in the VII National Congress
zados en algunos cursos de Atencin Farmacutica of General Medicine, celebrated in Granada, Dr Solla,
a distancia, con el objetivo de ensear Farmacologa the Spanish representative of General Practitioners in
y Farmacoterapia, han ocasionado que en el VII the European Union, considered them a clear example
Congreso Nacional de Medicina General, celebrado of interference. In the sequence of activities considered
en Granada, el Dr. Solla, representante espaol en la by some as Pharmaceutical Care, the patient was sub-
Unin Europea de Mdicos Generales, los considere mitted to a physical exploration, diagnostic tests were
un claro ejemplo de intrusismo. En la secuencia de requested, and therapeutic plans were established
actividades considerada por algunos como Atencin including or not medicines. If these activities constitute
Farmacutica, se somete al enfermo a una explora- the professional competence of our own process, then
cin fsica, se solicitan pruebas diagnsticas y se Pharmaceutical Care would be nothing but a poor imi-
establecen planes teraputicos incluyendo o no tation of the medical process.
incluyendo medicamentos. Si estas actividades cons- However, not to carry out physical exploration, does
tituyesen el proceso propio de nuestra competencia not mean that the pharmacists have to be blindfolded
profesional, la Atencin Farmacutica no sera ms themselves so as to attend those who use medicines
que una mala imitacin del proceso de Atencin under their competence; Not to request laborator y
Mdica. tests should not become "entrance forbidden" to analy-
Ahora bien, no realizar exploraciones fsicas no tic figures which suppose control over the parameters
quiere decir que los farmacuticos tengan que in relation to the good or bad use of medicines; Not to
taparse los ojos para atender a los que usan medi- establish therapeutic plans must not impede agree-
camentos bajo su competencia; no solicitar pruebas ment between the pharmacist and the patient of tem-
diagnsticas no puede conver tirse en "acceso prohi- poral plans in order to improve the use or compliance
bido" a las cifras de analticas que suponen control of certain medicines and to be able to test them.
de parmetros en relacin con el buen o mal uso This editorial would like to point to the possible
de medicamentos; no establecer planes teraputicos minimum agreement between a general practitioner
no puede impedir el acuerdo entre farmacutico y and a community pharmacist if we want to obtain a)
paciente de planes temporales para mejorar la utili- an effective and healthy use of medicines, and b) the

Pharm Care Esp 2000; 2: 147-150 147


F. Abal Ferrer et al.

zacin o el cumplimiento de cier tas medicaciones y most efficient exploitation of the health professionals
poder comprobarlo. available. The agreement had the following prior reflec-
Este editorial quiere sealar el acuerdo de mni- tion by the general practitioner:
mos posible entre un mdico general y un farma- "This thing about interference has made me
cutico comunitario si queremos conseguir : a) un work. The word is ugly and produces rejection. I ask
uso efectivo y saludable de los medicamentos y b) myself if it has something to do with ingest1. I take a
el aprovechamiento ms eficiente de los profesiona- look at the dictionary and the whacking great book
les sanitarios disponibles. shackles me. It's a question of space. Lots of words.
El acuerdo ha tenido la siguiente reflexin previa The solution was to make the letters smaller. Time
por par te del mdico general: does not pass in vain and I need help from my glas-
"Eso de la injerencia me ha hecho trabajar. La ses. But even then I have to make an effor t.
palabra es fea y produce rechazo. Me pregunto si My sight was tested by an ophthalmologist friend
tiene algo que ver con ingerir. Me asomo al diccionario of mine. In her waiting room there is a sign which
y el til mamotreto me pone trabas. Es cuestin de clearly and explicitly expresses that the ophthalmo-
espacio. Muchas palabras. La solucin fue poner la logist is the sole person authorized to prescribe and
letra ms pequea. Los aos no pasan en balde y instill eye-drops. This affected me directly but I didn't
necesito ayuda de las gafas. Aun as tengo que esfor- say anything. I doubt its legal value and even more
zarme. so its truthfulness. After her assistant had irrigated
La vista me la grada una amiga oftalmlogo. En my eyes she gave me the eye test.
su sala de espera hay un cartel que expresa clara y This same week, in the afternoon, a man came to
explcitamente que el oftalmlogo es el nico autoriza- my clinic. He had been prescribed eye-drops. He
do para prescribir e instilar colirios. Me afecta directa- lives alone. He is not capable of instilling the eye-
mente pero nunca le coment nada. Dudo de su valor drops himself. His sister isn't at home. I put them in,
legal y mucho ms de su veracidad. Despus de que and according to my friend's notice, I meddled (at
su auxiliar me regase los ojos ella me hizo la gradua- least as much as her assistant). The man went away
cin. grateful and ignorant of the fact that my act could
Esta misma semana, por la tarde, un hombre acu- be termed criminal.
di al Centro de Salud. Le haban prescrito un colirio. Because if one talks of interference, one is talking
Vive solo. No es capaz de auto-instilarse. Su hermana of meddling. The latter contemplated in the Penal
no est en casa. Se las echo yo y, segn el cartel de mi Code where crimes are to be found and this con-
amiga, injiero (al menos tanto como su auxiliar). El ver ts those who practice it into delinquents.
hombre se fue agradecido e ignorante de que mi acto We, Primar y care physicians, were accused of
pudiese ser delictivo. meddling by carrying out minor surgery, the taking
Porque s. Se habla de injerencia, se habla de intru- of cervix smears, the emplacing of IUDs, the taking
sismo. Esto ltimo contemplado en el Cdigo Penal of echography, the follow up of pregnancies and
donde figuran los delitos y convierte en delincuentes a many more things which I don't remember and
quienes los practican. others I prefer not to (It has got to the point of
A los mdicos de Atencin Primaria se nos acus asking that general practitioners should not have
de intrusismo por hacer ciruga menor, toma de citolo- access to primary care entrance exams).
gas, poner DIU, hacer ecografas, seguir embarazos y This is a problem of bread and not of work. Is
ms cosas que no recuerdo y otras que prefiero no there anybody who believes that the most reasona-
recordar (se lleg a pedir que los mdicos generales no ble thing to do was to have sent that man to the
tuvieran acceso a las oposiciones de Atencin ophthalmologist?. Put your hand up!. It will stand out
Primaria). so much I will see it from here.
Es un problema de pan, no de trabajo. Alguien Now another front has opened up. There is a lot
cree que lo razonable habra sido mandar a ese hom- of play in Pharmaceutical Care. How is a pharmacist
bre a un oftalmlogo? Que levante la mano! going to take someone's blood pressure or look at
Destacar tanto que yo lo ver desde aqu. glycemia (let alone interpret it). Madness!. And what
Ahora se abre otro frente. Es que eso de la about medicines?. To take notice of interactions, over-
Atencin Farmacutica da mucho juego. Cmo un far- doses, duplicity, allergies and all those drug-related
macutico va a tomar una tensin arterial o mirar una problems seems to be nobody's business.These crimi-
glucemia (y ms interpretarla)? De locos! Y de los nal activities are done after the medical consultation
medicamentos? Darse cuenta de interacciones, sobre-
dosificacin, duplicidad, alergias y todos aquellos pro-
blemas relacionados con medicamentos parecen no 1
Translator note: In Spanish language, meddling and ingest sound very
ser asunto de nadie. Estas actividades delictivas se similar (injerencia and ingesta).

148 Pharm Care Esp 2000; 2: 147-150


F. Abal Ferrer et al.

zacin o el cumplimiento de cier tas medicaciones y most efficient exploitation of the health professionals
poder comprobarlo. available. The agreement had the following prior reflec-
Este editorial quiere sealar el acuerdo de mni- tion by the general practitioner:
mos posible entre un mdico general y un farma- "This thing about interference has made me
cutico comunitario si queremos conseguir : a) un work. The word is ugly and produces rejection. I ask
uso efectivo y saludable de los medicamentos y b) myself if it has something to do with ingest1. I take a
el aprovechamiento ms eficiente de los profesiona- look at the dictionary and the whacking great book
les sanitarios disponibles. shackles me. It's a question of space. Lots of words.
El acuerdo ha tenido la siguiente reflexin previa The solution was to make the letters smaller. Time
por par te del mdico general: does not pass in vain and I need help from my glas-
"Eso de la injerencia me ha hecho trabajar. La ses. But even then I have to make an effor t.
palabra es fea y produce rechazo. Me pregunto si My sight was tested by an ophthalmologist friend
tiene algo que ver con ingerir. Me asomo al diccionario of mine. In her waiting room there is a sign which
y el til mamotreto me pone trabas. Es cuestin de clearly and explicitly expresses that the ophthalmo-
espacio. Muchas palabras. La solucin fue poner la logist is the sole person authorized to prescribe and
letra ms pequea. Los aos no pasan en balde y instill eye-drops. This affected me directly but I didn't
necesito ayuda de las gafas. Aun as tengo que esfor- say anything. I doubt its legal value and even more
zarme. so its truthfulness. After her assistant had irrigated
La vista me la grada una amiga oftalmlogo. En my eyes she gave me the eye test.
su sala de espera hay un cartel que expresa clara y This same week, in the afternoon, a man came to
explcitamente que el oftalmlogo es el nico autoriza- my clinic. He had been prescribed eye-drops. He
do para prescribir e instilar colirios. Me afecta directa- lives alone. He is not capable of instilling the eye-
mente pero nunca le coment nada. Dudo de su valor drops himself. His sister isn't at home. I put them in,
legal y mucho ms de su veracidad. Despus de que and according to my friend's notice, I meddled (at
su auxiliar me regase los ojos ella me hizo la gradua- least as much as her assistant). The man went away
cin. grateful and ignorant of the fact that my act could
Esta misma semana, por la tarde, un hombre acu- be termed criminal.
di al Centro de Salud. Le haban prescrito un colirio. Because if one talks of interference, one is talking
Vive solo. No es capaz de auto-instilarse. Su hermana of meddling. The latter contemplated in the Penal
no est en casa. Se las echo yo y, segn el cartel de mi Code where crimes are to be found and this con-
amiga, injiero (al menos tanto como su auxiliar). El ver ts those who practice it into delinquents.
hombre se fue agradecido e ignorante de que mi acto We, Primar y care physicians, were accused of
pudiese ser delictivo. meddling by carrying out minor surgery, the taking
Porque s. Se habla de injerencia, se habla de intru- of cervix smears, the emplacing of IUDs, the taking
sismo. Esto ltimo contemplado en el Cdigo Penal of echography, the follow up of pregnancies and
donde figuran los delitos y convierte en delincuentes a many more things which I don't remember and
quienes los practican. others I prefer not to (It has got to the point of
A los mdicos de Atencin Primaria se nos acus asking that general practitioners should not have
de intrusismo por hacer ciruga menor, toma de citolo- access to primary care entrance exams).
gas, poner DIU, hacer ecografas, seguir embarazos y This is a problem of bread and not of work. Is
ms cosas que no recuerdo y otras que prefiero no there anybody who believes that the most reasona-
recordar (se lleg a pedir que los mdicos generales no ble thing to do was to have sent that man to the
tuvieran acceso a las oposiciones de Atencin ophthalmologist?. Put your hand up!. It will stand out
Primaria). so much I will see it from here.
Es un problema de pan, no de trabajo. Alguien Now another front has opened up. There is a lot
cree que lo razonable habra sido mandar a ese hom- of play in Pharmaceutical Care. How is a pharmacist
bre a un oftalmlogo? Que levante la mano! going to take someone's blood pressure or look at
Destacar tanto que yo lo ver desde aqu. glycemia (let alone interpret it). Madness!. And what
Ahora se abre otro frente. Es que eso de la about medicines?. To take notice of interactions, over-
Atencin Farmacutica da mucho juego. Cmo un far- doses, duplicity, allergies and all those drug-related
macutico va a tomar una tensin arterial o mirar una problems seems to be nobody's business.These crimi-
glucemia (y ms interpretarla)? De locos! Y de los nal activities are done after the medical consultation
medicamentos? Darse cuenta de interacciones, sobre-
dosificacin, duplicidad, alergias y todos aquellos pro-
blemas relacionados con medicamentos parecen no 1
Translator note: In Spanish language, meddling and ingest sound very
ser asunto de nadie. Estas actividades delictivas se similar (injerencia and ingesta).

148 Pharm Care Esp 2000; 2: 147-150


Nos injerimos? / Are we meddling?

hacen despus de la consulta del mdico y si el farma- and if the pharmacist does not interfere or meddle,
cutico no se interpone, interfiere o injiere el paciente the patient has no protection against these problems.
se queda sin una proteccin contra estos problemas. Authorities make available to our prescription
Las autoridades hacen disponibles a nuestra pres- medicines that are considered to be efficacious,
cripcin unos medicamentos que se consideran eficaces; some of which are later qualified as of low thera-
an as, desde el propio ministerio, algunos de ellos son peutic value or of null innovation. So I can someti-
luego calificados como de utilidad teraputica baja o de mes doubt the efficacy of some medicines, but don't
nula innovacin. Puedo entonces dudar a veces de la efi- doubt the bad use made of them and of which, even
cacia de algunos medicamentos, pero no dudo del mal being less the desired efficacy, the effectiveness is far
uso que se hace de ellos y de que, aun siendo la eficacia from it. And what if among us all we elevate it?. With
menor de la deseada, la efectividad est muy lejos de pharmacists who meddle?.
ella. Y si ayudamos entre todos a elevarla? con farma- If in order to obtain a major effectiveness of the
cuticos que se injieren? use of medicines in patients that I attend, I have to
Si para conseguir mayor efectividad del uso de become a delinquent, tell me where I have to sign
medicamentos en los pacientes que yo atiendo hay up."
que hacerse delincuente, dgame usted donde tengo After this reflection, it has been easy for us to the
que apuntarme." following minimum points:
Tras esta reflexin, nos ha sido fcil consensuar With respect to the "pharmaceutical consultations",
los siguientes puntos mnimos: Yes, indeed consult; The same as there exist legal or
Respecto a las "consultas farmacuticas" S, con- engineering, financial investments, or gardening, ... or
sulta; como existen consultas jurdicas, o de ingenie- physicians consultations. Even though they are all
ra o de inversin financiera o de jardinera.o called consultations the objectives the user has when
mdicas. An llamndose todas "consultas" los obje- he or she visits them and the procedure used by the
tivos que el usuario tiene cuando acude a ellas y los professional in order to resolve the consulter's doubts
procedimientos utilizados por el profesional para are different. We visit them when we are confident that
resolver las dudas del consultante son diferentes. A a professional (who has acquired special technical
ellas se acude cuando confiamos en que un profe- knowledge in a determined field of learning) can resol-
sional (que ha adquirido especiales conocimientos ve our problems or doubts on something that affects
tcnicos en un campo determinado del saber) us. A physician's clinic is visited because the professio-
puede resolver nuestros problemas o dudas sobre nal, who knows about illnesses and how to treat them
algo que nos afecta. A la consulta mdica se acude knows how to fix and resolve what is wrong with us.
para que el profesional que sabe de enfermedades y Logically the consultation does not end with the first
de cmo tratarlas resuelva qu nos pasa y cmo visit but with the epilogue of observing the result of the
arreglarlo. Lgicamente la consulta no se cierra con established therapeutic plan, a responsibility as medi-
la primera visita sino con el eplogo de observar el cal as the diagnosing and establishing of therapy. The
resultado del plan teraputico establecido, responsa- pharmacist's consultation is visited so that the profes-
bilidad tan mdica como la de diagnosticar y esta- sional, who knows about medicines and how too use
blecer la teraputica. A la consulta farmacutica se them, indicated to us which of the medicines in the
acude para que el profesional que sabe de medica- pharmacy may be the most efficacious to control the
mentos y de cmo usarlos, nos indique cul de los symptoms we have and which we ourselves have con-
medicamentos que tiene en la farmacia puede ser sidered banal and susceptible to self-.medication. In
ms eficaz para controlar la sintomatologa que this situation there are always some primar y filter-
tenemos y que nosotros mismos hemos considera- questions to refer those consultations to medical care
do banal y susceptible de automedicacin. En esa that the pharmacist considers that what the individual
situacin hay siempre unas primeras preguntas-filtro considers banal and self-medicable, by his professional
para derivar a la asistencia mdica aquellas consultas judgement is not so. On the other hand, the medicine
en las que el farmacutico considera que lo que al indicated by the pharmacist are always non-prescrip-
ciudadano le parece banal y automedicable, a su jui- tion medicines, and it is evident that he or she knows
cio no lo es. Por otra par te, los medicamentos a better than the rest of the citizens their indications,
indicar por el farmacutico son siempre de "no- efficacy and safety.
prescripcin mdica" y es evidente que conoce With respect to the access and data registration of
mejor que el resto de los ciudadanos sus indicacio- medicine users: All the data of biological parameters,
nes, eficacia y seguridad. past or modern, that could help the identification of
Respecto al acceso y registro de datos del usua- problems in effectiveness or safety in the use of medi-
rio de medicamentos: Todos los datos de parme- cines should be known by the pharmacist. Their records
tros biolgicos, actuales o pasados, que puedan ayu- and files will be submitted to the same requirements

Pharm Care Esp 2000; 2: 147-150 149


F. Abal Ferrer et al.

dar a la identificacin de problemas de efectividad o of privacy and confidentiality as the rest of the health
seguridad en el uso de medicamentos deben y pue- care documentation.
den ser conocidos por el farmacutico. Sus registros With respect to the evaluation of available informa-
y archivos estarn sometidos a las mismas exigencias tion by the pharmacist: Having obtained the informa-
de privacidad y confidencialidad que el resto de la tion that results from data and that revealed by the
documentacin clnico-sanitaria. patient or his or her caregiver, the pharmacist evalua-
Respecto a la evaluacin por el farmacutico de tion will always deal with the possible cause of a
la informacin disponible: Recogida la informacin determined way of medicines used; and the lack of
que se deriva de los datos y de lo manifestado por effectiveness, the appearance of toxicity, and the lack
el enfermo o su cuidador, la evaluacin del farma- or excess of indication of these medicines used.
cutico versar siempre sobre la posible causalidad With respect to the decision to inter vene in the
de un modo determinado de usar medicamentos y process of use of medicines by patient/users: Having
la falta de efectividad, la aparicin de toxicidad y la evaluated the information, the decision to intervene in
falta o exceso de indicacin de esos medicamentos the use of medicines with the aim of improving health
en uso. results, has a counterweight to assume the responsible
Respecto a la decisin de intervenir en el proce- professional part that responds to it.
so de uso de medicamentos por los pacientes/usua- Pharmaceutical Care has to this moment demons-
rios. Evaluada la informacin, la decisin de interve- trated the diminishing of illness days in asthmatic
nir en el uso de medicamentos con la finalidad de patients; reducing the number of hospitalizations, the
mejorar los resultados sanitarios, tiene como con- length of stay and suffering of relapses in patients with
trapar tida asumir la par te de responsabilidad profe- cardiac impairments and coronar y illness; increasing
sional que corresponda. the compliance in the antibiotic treatment, including
La Atencin Farmacutica ha demostrado hasta anti-tuberculosis treatments; that is to say: intervening
el momento disminuir los das de enfermedad en los in the use, it improves the medicines effectiveness.
pacientes asmticos, rebajar el nmero de hospitali- In conclusion: The conflict of domain or strict immo-
zaciones, das de hospitalizacin y recadas por vable demarcation of professional limits should recogni-
enfermedad en los pacientes con insuficiencia car- ze as superior interests the welfare of the individuals
diaca y con enfermedad coronaria, aumentar el to which the service is provided and mold themselves
cumplimiento en los tratamientos con antibiticos, to the demands of change which the new health care
incluidos los tratamientos antituberculosos, es decir : necessities provoke in a population which uses medici-
interviniendo sobre el uso, se mejora la efectividad nes in a greater quantity then ever, in an innovating
de medicamentos. way and during an unlimited length of time.
En conclusin: los conflictos de competencias o
demarcacin estricta e inamovible de lmites profe- Francisco Abal Ferrer
sionales deben reconocer como inters superior el MD. General Practitioner in Carbayin Alto,
bienestar de los individuos a los que se presta el Siero (Asturias)
servicio y amoldarse a la exigencia de cambio que
provocan las nuevas necesidades de atencin sanita- Flor lvarez de Toledo Saavedra
ria en una poblacin que utiliza medicamentos en BSC. Pharm. Community Pharmacist in Oviedo
mayor cantidad que nunca, de modos innovadores y
durante tiempos sin lmite.

Francisco Abal Ferrer


Licenciado en Medicina
Mdico General en Carbayin Alto, Siero (Asturias)

Flor lvarez de Toledo Saavedra


Licenciada en Farmacia
Farmacutica comunitaria en Oviedo.

150 Pharm Care Esp 2000; 2: 147-150