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Old 30.04.2015, 18:21
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Growing crisis in general medicine: Expanding the pharmacist's remit?

As Switzerland grapples with the looming crisis due to lack primary care physicians*, a proposal is under discussion in Parliament to allow more 'front line' care to be provided by pharmacists rather than doctors, according to a 20Minuten article:

http://www.20min.ch/schweiz/news/story/18872837

This proposal might allow pharmacists to provide vaccinations, write prescriptions for certain meds, to offer advise on medical conditions.

This would mean additional training for pharmacists, the article points out.

I'm of two minds on this.

On the one hand, as I sit here suffering from 'something' that while waiting for a chance to see the doctor (first available appointment: 3 weeks) has likely turned into a nasty bronchial infection, it would be nice if in acute cases one could get some kind of qualified advice in a timely fashion.

On the other hand, I do worry that this is a bit of a band-aid rather than what seems to me to be needed - a serious look at why doctors do not want to go into general practice anymore.

---

*According to the article, the lack of GPs is not just a problem in the boondocks. In Zürich city only 32 out of 200 GPs are currently taking on new patients.

And the numbers are likely worse than they appear on paper. A good portion of doctors, especially young doctors, only work part time.

---

So - what do you think, folks?
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Old 30.04.2015, 21:13
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

Why would one go to all the trouble to become a doctor when the hours are so poor and the remuneration is far more lucrative to become a banker here?

On a more serious note this is a tough one and it's not just Switzerland that is grappling with these issues. Even worse, Switzerland is loosing it's ability to recruit from abroad and still not stepping up to educate enough doctors here in Switzerland.

As far as the pharmacist go, I'd be very hesitant to depend on them alone to manage my health. I have a more complicated situation than most so from my perspective it wouldn't be helpful. When ever I have any specific questions about my medications the pharmacist generally need to go to their computers to look up the information. Other than my prescription history they have no knowledge of my medical condition or history. I find they are often confused and I've I had to correct their mistakes on the dispensing information. I personally wouldn't be comfortable to depend on them outside of basic health issues. Back home many medications were made available over the counter to help ease this burden, some medications are held behind the counter for further counseling to make sure there was no abuse but generally I think that's also something that should be considered here too.

I think it would be far more beneficial and cost efficient to have qualified nurse practitioners working along with the doctors to help oversee the day to day issues that many doctors simply can't keep up with. Personally I'd have more trust with a nurse practitioner who knows my medical history better from working along side with my GP to help manage these things.

The whole point of pharmacists moving into this area, starting to providing medical diagnosis's is very political. Both professional organizations have been fighting each other hard over this territory.

I recently changed my GP due to retirement to a new doctor in the next Kanton. I'm in that area between Schwyz, Zug and Luzern. My new doctor doesn't dispense medications and it's become a real night-mirror for me to manage all the bills with the insurer. My old doctor in Kanton Schwyz dispensed medications plus he also billed my insurer directly for his bills so it was all easy peasy. I'd just get a notice from the insurer to pay the balance due for my franchise or items not covered. Not so now.

The other issue to consider is that pharmacists all charge quite some hefty dispensing fees, for every single prescription despite the fact that most prescriptions at least for me are repeats. My old doctor didn't charge that at all, ever. I don't think this fee is appropriate, I don't get any counseling from the pharmacist on my medications unless I ask specifically. Usually it is an assistant handling everything not even the pharmacist him or herself. More so my red flags go up when I think back to the fact that not one pharmacists or assistant here have ever asked me about my known allergies and since I just about died from one of the medications commonly prescribed here but banned in many other countries I think it's a question that should be asked to every patient before dispensing.
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Old 30.04.2015, 21:53
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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I think it would be far more beneficial and cost efficient to have qualified nurse practitioners working along with the doctors to help oversee the day to day issues that many doctors simply can't keep up with. Personally I'd have more trust with a nurse practitioner who knows my medical history better from working along side with my GP to help manage these things.
This is the route the US has gone, and I think it's brilliant. I've heard resistance here, as people don't understand that in the US nurses have a different clinical education, nursing is a university degree, and an NP is a post-grad degree, either an MSc or PhD.

The NP can write prescriptions, provide a wide range of care - in fact, those I know are better 'doctors' than many an MD.

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The whole point of pharmacists moving into this area, starting to providing medical diagnosis's is very political. Both professional organizations have been fighting each other hard over this territory.
Very interesting point. I see the spectre of mission creep on the horizon. You are right about the whole kerfluffle about doctors dispensing medicine at the practice - a pure money grab by the Apotheke lobby, to the detriment of patients.

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I don't get any counseling from the pharmacist on my medications unless I ask specifically. Usually it is an assistant handling everything not even the pharmacist him or herself.
Another good point - now that you mention it, I've never spoken to a pharmacist, only to the sales clerks - who clearly only know how to work a register. And peddle homeopathy.

As I was at the Apotheke today it also hit me - you stand there, within hearing of other customers, describing your symptoms - there is no possibility for privacy as one would expect seeing a doctor.
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Old 30.04.2015, 22:33
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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This is the route the US has gone, and I think it's brilliant. I've heard resistance here, as people don't understand that in the US nurses have a different clinical education, nursing is a university degree, and an NP is a post-grad degree, either an MSc or PhD.

The NP can write prescriptions, provide a wide range of care - in fact, those I know are better 'doctors' than many an MD.



Very interesting point. I see the spectre of mission creep on the horizon. You are right about the whole kerfluffle about doctors dispensing medicine at the practice - a pure money grab by the Apotheke lobby, to the detriment of patients.



Another good point - now that you mention it, I've never spoken to a pharmacist, only to the sales clerks - who clearly only know how to work a register. And peddle homeopathy.

As I was at the Apotheke today it also hit me - you stand there, within hearing of other customers, describing your symptoms - there is no possibility for privacy as one would expect seeing a doctor.
Privacy is a big problem in pharmacies here and unless they make physical changes to their retail dispensing outlets, which would be difficult in many situations, patient privacy will continue to be disregarded.

And as far as the whole homeopathy thing goes pharmacists shops should be ruled under the same standards as medical doctors (not allowed to advertise) if they are going to start diagnosing. If not then the whole shabang should be open up wide so we could get the full range of vitamins and nutricuticals and cost benefits available elsewhere without being governed under the very expensive Swiss Medic license but that probably wouldn't go well with the lobby in Bern.

A good example of how this works here is this: I was prescribed an Ayervedic medication, some would beg to differ on whether it is in fact a medication, but it was prescribed by a Swiss doctor . The only problem is that I can only get it from a specific pharmacy located in Apenzella. My doctor said don't question it, it's a Swiss thing but he also quickly advised me not to purchase the same ingredient over the internet. It is covered under my extended Zustazversicherung minus my deduction and minus the postal charges, which are not cheap here. But the kicker is that in total the cost is huge compared to what it would cost for an equivalent quality of the same ingredient in Germany. More than double the price I am forced to pay so in the end one small pharmacy is protected but the whole industry is blocked and consumer rights are completely disregarded not to mention the fact that insurance premiums for everyone are increased.
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Old 30.04.2015, 23:17
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

On the note of pharmacists being trained to vacinate against tick bites please be aware that the vacination is only against one of the diseases spread by these ticks. https://www.ch.ch/en/ticks/ tick-borne encephalitis (TBE) (early summer meningo-encephalitis ESME) It does not protect you against Lyme disease. Perhaps they'll be good for a jab like the school nurse is trained to do but I wouldn't want them to start diagnosing without more significant education. Even doctors have great difficulty diagnosing and treating Lyme borreliosis / Lyme diseas, lab results are often inconclusive. I was very fortunate to have had a doctor who was able to clinically diagnose the lymes disease early enough to treat it with antibiotics despite the inconclusive lab results. I doubt Pharmacists will be trained extensively enough to manage the signs and symptoms of diseases like Lyme without a full medical education.

Why don't they just go to medical school and become doctors?
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Old 30.04.2015, 23:34
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

This raises a whole set of issues.

I do not know how it is here but in other countries the qualifications you need to study pharmacy are lower than those you need to start training to be a doctor.

In UK for example "There are no minimum entry requirements to enter training as a pharmacy technician"

The full training to be a Pharmacist in UK is at a much higher level and is a 5 year course
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Old 30.04.2015, 23:37
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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On the note of pharmacists being trained to vacinate against tick bites please be aware that the vacination is only against one of the diseases spread by these ticks. https://www.ch.ch/en/ticks/ tick-borne encephalitis (TBE) (early summer meningo-encephalitis ESME) It does not protect you against Lyme disease. Perhaps they'll be good for a jab like the school nurse is trained to do but I wouldn't want them to start diagnosing without more significant education. Even doctors have great difficulty diagnosing and treating Lyme borreliosis / Lyme diseas, lab results are often inconclusive. I was very fortunate to have had a doctor who was able to clinically diagnose the lymes disease early enough to treat it with antibiotics despite the inconclusive lab results. I doubt Pharmacists will be trained extensively enough to manage the signs and symptoms of diseases like Lyme without a full medical education.

Why don't they just go to medical school and become doctors?
Because the roles of a nurse/a chemist/a doctor are different. The edu is different, so is the actual job. I'd just improve the general situation of doctors in order for them to actually want to do their job here. Not push other occupations to substitute and compensate. Not saying nurses and pharmasists shouldn't train more, here, in fact they fall behind in work product compared to what I have experienced elsewhere. I think it is just overall too expensive to train people here.
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Old 30.04.2015, 23:43
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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As Switzerland grapples with the looming crisis due to lack primary care physicians*, a proposal is under discussion in Parliament to allow more 'front line' care to be provided by pharmacists rather than doctors, according to a 20Minuten article:

http://www.20min.ch/schweiz/news/story/18872837

This proposal might allow pharmacists to provide vaccinations, write prescriptions for certain meds, to offer advise on medical conditions.

This would mean additional training for pharmacists, the article points out.

I'm of two minds on this.

On the one hand, as I sit here suffering from 'something' that while waiting for a chance to see the doctor (first available appointment: 3 weeks) has likely turned into a nasty bronchial infection, it would be nice if in acute cases one could get some kind of qualified advice in a timely fashion.

On the other hand, I do worry that this is a bit of a band-aid rather than what seems to me to be needed - a serious look at why doctors do not want to go into general practice anymore.

---

*According to the article, the lack of GPs is not just a problem in the boondocks. In Zürich city only 32 out of 200 GPs are currently taking on new patients.

And the numbers are likely worse than they appear on paper. A good portion of doctors, especially young doctors, only work part time.

---

So - what do you think, folks?
I just turned up at the HMO group practice when I was ill, I got seen within 20 minutes & that was without an appointment. I guess thats the benefit of going to a group practice.
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Old 01.05.2015, 00:48
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

I go to a group practice too and I'm seen very quickly as always. The difference between your HMO medical practice and mine is that yours is owned and operated by an insurance company that manages your care, mine is owned and operate and the doctors.

But that's aside from the point of this thread, the issue at hand is ultimately about lowering costs. Some think having pharmacist learn how to diagnose medical conditions is the easier cheaper quick solution. For some minor issues it could help but it still won't replace the need of patients to see their doctors for a full proper physical exam. And then one needs to consider the risks associated with potential misdiagnosis's. How would the state now deal with complaints and malpractice issues when a pharmacist diagnoses medical complaints and doesn't get it right?

The other consideration is that it's not always necessary for a great many many health issues to be dealt with by pharmacological interventions. Modern medicine has been pushed by the big $$$ behind the pharmaceutical industry to believe that is the right way. Who else would be better proponents of that message then pharmacists themselves, ah ha!
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Old 01.05.2015, 03:50
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

A p'roblem is that now, even fully educated pharmacists simply hand out medicaments prescribed by the doctors. Up into the 1950ies, pharmacists took the doc's recipe and mixed the various ingredients and either sold the resulting pulver or pressed the stuff into tablets. They also were in charge with gardening problems. You told them what the matter was (insects etc) and they mixed something to tackle the matter.


The chief pharmacists are well educated people who in practice act as expensive cashiers of the "chemical Mafia". Why not giving them back a real role
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Old 01.05.2015, 04:20
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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Why would one go to all the trouble to become a doctor when the hours are so poor and the remuneration is far more lucrative to become a banker here?

On a more serious note this is a tough one and it's not just Switzerland that is grappling with these issues. Even worse, Switzerland is loosing it's ability to recruit from abroad and still not stepping up to educate enough doctors here in Switzerland.

As far as the pharmacist go, I'd be very hesitant to depend on them alone to manage my health. I have a more complicated situation than most so from my perspective it wouldn't be helpful. When ever I have any specific questions about my medications the pharmacist generally need to go to their computers to look up the information. Other than my prescription history they have no knowledge of my medical condition or history. I find they are often confused and I've I had to correct their mistakes on the dispensing information. I personally wouldn't be comfortable to depend on them outside of basic health issues. Back home many medications were made available over the counter to help ease this burden, some medications are held behind the counter for further counseling to make sure there was no abuse but generally I think that's also something that should be considered here too.

I think it would be far more beneficial and cost efficient to have qualified nurse practitioners working along with the doctors to help oversee the day to day issues that many doctors simply can't keep up with. Personally I'd have more trust with a nurse practitioner who knows my medical history better from working along side with my GP to help manage these things.

The whole point of pharmacists moving into this area, starting to providing medical diagnosis's is very political. Both professional organizations have been fighting each other hard over this territory.

I recently changed my GP due to retirement to a new doctor in the next Kanton. I'm in that area between Schwyz, Zug and Luzern. My new doctor doesn't dispense medications and it's become a real night-mirror for me to manage all the bills with the insurer. My old doctor in Kanton Schwyz dispensed medications plus he also billed my insurer directly for his bills so it was all easy peasy. I'd just get a notice from the insurer to pay the balance due for my franchise or items not covered. Not so now.

The other issue to consider is that pharmacists all charge quite some hefty dispensing fees, for every single prescription despite the fact that most prescriptions at least for me are repeats. My old doctor didn't charge that at all, ever. I don't think this fee is appropriate, I don't get any counseling from the pharmacist on my medications unless I ask specifically. Usually it is an assistant handling everything not even the pharmacist him or herself. More so my red flags go up when I think back to the fact that not one pharmacists or assistant here have ever asked me about my known allergies and since I just about died from one of the medications commonly prescribed here but banned in many other countries I think it's a question that should be asked to every patient before dispensing.

It is clearly the customer who has to tell about allergies, as there are so many allergies around that it also for a doc is impossible to ask for everything. And Switzerland still can recruit doctors and pharmacists as needed. BUT not too long ago there were TOO MANY medical doctors coming from University. And so, they pulled the plug. Such things often are regional. A certain Mrs L... from the Canton of Bern in about 1920 had tp realise that there were far too many teachers in her Canton and so went to the Canton of Schaffhausen where they did not have enough teachers. An additional thing for her was that the Schaffhauser do NOT understand Bernese so that she from day one in SH only spoke High German. She retired finally in the early 1950ies
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Old 01.05.2015, 10:10
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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It is clearly the customer who has to tell about allergies, as there are so many allergies around that it also for a doc is impossible to ask for everything.
How am I to know if a new medication has a similar ingredient that could be a problem with an allergy or an interaction with another medication. It's a rather simple question to ask to make sure the system is working right and errors aren't made. Yes of course the doctor should be aware of any allergy issues but it can often get berried and missed. It's the least that could be expected from a pharmacist for the dispensing fees they charge.

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And Switzerland still can recruit doctors and pharmacists as needed.
Yes this is true but with the new attitude towards immigration along with the stronger franc many of these professionals have less incentives to make such a life/work change to come work here. That plus working conditions and salary levels have generally improved at least in places like Germany where a large number of these professionals have previously been recruited from. I read in the paper that recruitment is now moving over to eastern European professional and many recruitment agencies and hospitals offer language classes to help get them up to a B2 level. Still it doesn't address the large number of GP practices in the smaller communities that are being closed as the wave of retirement hits all across Switzerland. There are simply not enough successors willing to make the investment required for a private practice and go outside of the major urban centers.

Perhaps a pharmacist can help some but their role would still be limited and in my mind it's not the answer to this growing crisis.
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Old 01.05.2015, 11:12
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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This raises a whole set of issues.

I do not know how it is here but in other countries the qualifications you need to study pharmacy are lower than those you need to start training to be a doctor.

In UK for example "There are no minimum entry requirements to enter training as a pharmacy technician"

The full training to be a Pharmacist in UK is at a much higher level and is a 5 year course
Pharmacists here do a full university or ETH study, same level and prerequisites as MDs.

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The chief pharmacists are well educated people who in practice act as expensive cashiers of the "chemical Mafia". Why not giving them back a real role
Sounds like a nice idea, but only at first look. Reverting to mixing drugs locally would raise a whole lot of issues, including quality and error rates. With todays requirements and specialisation that approach is simply out of question, will not happen.

The Kantonsspital St.Gallen has an internal pharmacy, the head of which also is the overseer ("Kantonsapotheker") and controller of all pharmacies in the Kanton. One of my brothers is his Stellvertreter (deputy?), he says the hospitals MDs often contact them to discuss medication and/or dosage in advance. I don't know if this also applies to "normal" MDs/pharmacists (neither do you, Wolli, know what happens behind the scenes), but it certainly would make sense as the pharmacist is the specialist on drugs, their pros and cons, contraindications and side-effects.

The typical MD will simply not be able to match, let alone surpass the pharmacists expertise on drugs. Additionally, if they do confer it adds an additional filter that improves safety as it reduces the chance for wrong medications and/or dosage.
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Old 01.05.2015, 13:51
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

I don't know the current situation in Switzerland, since the Bologna reform craze of the last decade messed up just about everything at our universities. Before Bologna, pharmacy was the longest and most demanding university course of study, significantly longer (at least six years) than what future MDs had to do. There were no Bachelor or Master degrees. A graduated pharmacists had gone through everything except a doctorate, which still could be added as the icing on the cake.

May be very different now, since Bologna often resulted in standardizing matters in a European framework but on an oftentimes lower level.
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Old 01.05.2015, 14:19
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

I don't think so. I actually just think that pharma biz pushing for a large number of pharmacies in a small area and unfortunately, the low affordability of a correctly licensed pharmacist resulted in having basically just a shop with many shop assistants and one pharmacist per shift. There are 4 pharmacies in my street. The pharma assistantship offers amazing opportunities for low edu jobs, CFC apprenticeships, training fields. But the one real pharmacist is overworked and the kids have managed to push some amazing bs on me more often than not, when I needed a qualified service. I wouldn't want to see the same situ with doctors, but I think people will just scoot over the border, just like they do for meds when they don't feel like battling the homeopathic and other potions campaigners here.
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Old 01.05.2015, 16:15
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

Studying Pharmacy at ETHZ took 8 semesters for the diploma, the same as all other courses at that time I'm aware of. IIRC the doctorate would have taken my brother an additional 1-2 years.

No idea about the situation today.
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Old 01.05.2015, 18:30
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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How am I to know if a new medication has a similar ingredient that could be a problem with an allergy or an interaction with another medication. It's a rather simple question to ask to make sure the system is working right and errors aren't made. Yes of course the doctor should be aware of any allergy issues but it can often get berried and missed. It's the least that could be expected from a pharmacist for the dispensing fees they charge.

Yes this is true but with the new attitude towards immigration along with the stronger franc many of these professionals have less incentives to make such a life/work change to come work here. That plus working conditions and salary levels have generally improved at least in places like Germany where a large number of these professionals have previously been recruited from. I read in the paper that recruitment is now moving over to eastern European professional and many recruitment agencies and hospitals offer language classes to help get them up to a B2 level. Still it doesn't address the large number of GP practices in the smaller communities that are being closed as the wave of retirement hits all across Switzerland. There are simply not enough successors willing to make the investment required for a private practice and go outside of the major urban centers.

Perhaps a pharmacist can help some but their role would still be limited and in my mind it's not the answer to this growing crisis.

A) You have to tell the doctor about your allergies. He DOES know the ingrédients of the medicines in question


B) the too strong CHF is an incentive to doctors from all over Europe


C) the wave of retirements (the baby-boomers getting retired and the baby-pill generation failing to close the gap) is fact


D) lots of SYRIAN professionals are now coming
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Old 01.05.2015, 19:37
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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Studying Pharmacy at ETHZ took 8 semesters for the diploma, the same as all other courses at that time I'm aware of. IIRC the doctorate would have taken my brother an additional 1-2 years.

No idea about the situation today.
I must admit my figures date back to the seventies. Back then, pharmacy at ETHZ was 12 semesters, at the University 13, medicine 11 and dentistry 10 (five semesters "pre-clinical" and five "clinical").

We had the very bad luck that after five "preclinical" semesters the syllabus got changed to four "pre-" and five "clinical." That meant that, after five "pre-" we had to do five "clinical" semesters too, in other words, one semester more than all those before and after us. There was no escape.

Of course there was no such crap as a bachelor degree back then.
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Old 02.05.2015, 01:16
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

It's a bit fuzzy (my memory) as it's 25-30 years since (he must have got his diploma '87 or '88) and at that age lots of other things are more important. If for example he had to do a "practice" year that may well have escaped my memory.

It's high time anyway he made good on his promise for that ice-cold beer(s), I'll be back (perhaps by PM until details have been sorted out).
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Old 02.05.2015, 11:05
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Re: Growing crisis in general medicine: Expanding the pharmacist's remit?

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Pharmacists here do a full university or ETH study, same level and prerequisites as MDs.

Sounds like a nice idea, but only at first look. Reverting to mixing drugs locally would raise a whole lot of issues, including quality and error rates. With todays requirements and specialisation that approach is simply out of question, will not happen.

The Kantonsspital St.Gallen has an internal pharmacy, the head of which also is the overseer ("Kantonsapotheker") and controller of all pharmacies in the Kanton. One of my brothers is his Stellvertreter (deputy?), he says the hospitals MDs often contact them to discuss medication and/or dosage in advance. I don't know if this also applies to "normal" MDs/pharmacists (neither do you, Wolli, know what happens behind the scenes), but it certainly would make sense as the pharmacist is the specialist on drugs, their pros and cons, contraindications and side-effects.

The typical MD will simply not be able to match, let alone surpass the pharmacists expertise on drugs. Additionally, if they do confer it adds an additional filter that improves safety as it reduces the chance for wrong medications and/or dosage.


The MD does by REZEPT tell the pharmacist what to hand out. The APOTHEKER therefore becomes the HAMPELMANN in charge. Alright, I am not informed about the behind-the-scčnes-conversations, but to improve the position of the pharmacists might really make sense


Many "customers" in a way FEAR the doctor but trust the chief pharmacist. The pharmacist also sells pesticides for the garden, equipment for kitchen and garden and balcony and so is the trusted man. My doctor just over the road gives out médicaments directly which is splendid.


I however still remember Mr J.... who was consulted by Mum between 1946 and about 1985 for everything in regard to her, me, brother, Dad, balcony and the garden ...... and who mixed stuff for us himself
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