Pharmacists Role in Complementary Alternative Medicines

Pharmacists Role in Complementary Alternative Medicines Pharmacists Role in Complementary Alternative Medicines The first section of this paper will provide background information on the use of complementary and alternative medicines (CAMs) and their associated risks and benefits. Additionally, information on the pharmacists’ role in CAMs and services in their pharmacies will be discussed. Next, the theory that potential ethical conflicts arise for pharmacists between keeping the health and wellbeing of clients and the community as their primary concern versus the prospect of turning a profit will be considered. Before concluding, other important ethical issues including duty of care, and liability will be discussed. Background The term CAM refers to any healing practise that doesn’t fall under the heading of conventional medicine. It encompasses not just pharmaceutical preparations, but diet, and traditional forms of health care including acupuncture, Chinese medicine, homeopathy, etc.1 In the past, people who sold CAMs were sometimes referred to as quacks, or someone who promotes unsupported methods that lack scientifically credible rational.2 CAMs were regarded as old wives tails, and their claims dismissed by the medical community.3   More recently CAMs have become a prominent feature in today’s health care regimens. In 2000 according to the Therapeutic Goods Administration (TGA) 52 percent of Australians were using at least one non-prescribed complementary medicine.4 The Therapeutic Goods Act of 1989 effectively legitimised CAMs by allowing them to be entered into the Australian Register of Therapeutic Goods (ARTG) as a listed medicine. They have to meet a lesser set of standards than conventional medicines, which is one of the major concerns of allopathic practioners.5 With the passing of this act, pharmacies could legitimately sell two types of products; medicines for which there is scientific evidence   (prescription and over the counter products) and unproven medications (some CAMs) that may lack efficacy.   There are many risks associated with using CAMS including direct risks, substitutions made, nonprofessional advice received, and unreliable diagnostic tests.6 In some cases, CAMs have caused serious harm. The adverse effects range from infection due to dirty acupuncture needles, altering the effectiveness of other pharmacologically proven agents, to death from chiropractic manipulation. Substitutions pose a great risk for serious conditions. Replacing conventional treatments with CAMs can lead to many adverse effects. For example, treating melanoma with a herbal ointment rather than surgery, radiotherapy, or chemotherapy can have disastrous consequences. Some patients, especially those with life threatening illnesses, will try anything to improve their symptoms. Some CAM practitioners take advantage of this and recommend treatments that are very costly and at the expense of other proven treatments. Unproven tests include, but aren’t limited to, reflexology and electro-dermal t esting.6 The danger in this type of testing is the high likelihood of misdiagnosis.   Despite the large body of evidence in the scientific community of the poor efficacy of CAMs, there is some evidence for their use as seen in cranberry for urinary tract infections St. John’s Wart for depression and a variety of others.7 In 1993 Australians spent an estimated 1 billion dollars on CAMs and by 2000 that number had risen to 2.3 billion.8   Shockingly, only 57 percent of Australians reported or discussed the use of these products to their doctors.9 The potential dangers outlined above and these statistics show the need for a pharmacists intervention. Pharmacist’s Role Pharmacists are a vital part of the allopathic health care team, often being the first port of call for patients requesting CAMs.10   The community pharmacy is an ideal environment to deliver quality, cost effective, and professional services to the general public. Patient’s safety and access to this high quality care is of paramount importance.11 Pharmacists counsel life style choices, recommend an appropriate non-prescription medication, or refer patient’s to a physician to improve outcomes.12      When responding to enquiries about CAMs pharmacists need to consider a variety of issues. The customers’ cultural and social beliefs and desire to take control of their own treatment should be viewed non-judgementally. Pharmacists need to stay up to date, and be aware of evidence to support the use of different products. Information about CAMs should be provided on an evidence-based level so the most accurate information is delivered to the patient. Pharmacist s also need to be aware of potential interactions with conventional products, and report adverse drug reactions to both the Adverse Drug Reaction’s Committee and the product’s sponsor.7 Furthermore, pharmacists must remind patients that CAMs are medications and should be openly discussed so potential interactions and side effects can be identified. Ethics and profit In a 2005 study of 484 community pharmacists in New South Wales 77% of respondents personally used CAMs and said that they offered CAM products for sale in their pharmacies. A majority of the pharmacists believed CAMs enhanced customers’ image of the pharmacy and 87% reported they increased customer numbers and annual sales.13 From these results it is evident that a potential conflict between promoting and selling CAMs and ethics could arise. Pharmacists are intrinsically placed in an ethical dilemma daily. They have dual roles as health care providers and businesspeople. As health care professionals they are expected to provide a high level of unbiased health care, while their business side is expected to sell products and generate a profit. Professional and business roles are generally believed to be in conflict with each other and roles are traditionally viewed as being exclusive. According to Chappell et al community pharmacists are one of the few occupations where professional and business values co-exist.   They found no correlation between the value placed on business and the level of care or â€Å"professionalism† displayed by the pharmacists. This suggests pharmacists are able to act dually as a salesperson but still deliver professional information.14 The degree of professionalism has been called into question by Kennedy et al. They demonstrated that in some cases pharmacists, especially proprietors, sometimes recommend more expensive products when a cheaper generic version is available, but the overall outcome was satisfactory. All pharmacists recommended an appropriate treatment for the condition but the product selected differed among owners and employee pharmacists. Although the patient received a high level of care, the fact that he or she had a cheaper option calls the level of professionalism into question.  Ã‚  Ã‚   Further evidence for professionalism is seen in a study by Perepelkin et al. where they found pharmacists, regardless of their ownership structure, are professionally oriented in their practise. The difference in services provided was only seen in terms of professional autonomy, decision-making and amount of control. There was no difference in the amount of profit-driven goals between the groups.16 Similarly, in a recent study, Kronus found that pharmacists, regardless of their role orientations (business versus professional), were similarly motivated by service and income values. She suggested that the theoretical model suggesting that business is based on extrinsic values and professionalism is based on altruistic values should be revised when talking about pharmacy. She found altruism (professionalism) was the dominant factor in the field of pharmacy. Since most pharmacists are salaried employees there is little pressure to increase profit by pushing CAMs with no supporting evidence. It would be very easy to jump to the conclusion that the need to make a profit would in some way have a negative effect on pharmacy owners or employed pharmacists (reward systems) to act as independent ethical health care providers when CAMs are viewed as huge profit generators.17 Wingfield et al suggest that ‘ethics is so integrated and intrinsic to daily practise that there is no need to single ethical issues for special attention,’ as demonstrated by a lack of a journal dedicated to pharmacy ethics (there are ethical journals for medicine and nursing). Rather the ethical behaviour of the pharmacist is displayed in all aspects of daily practise culling the drive for profits.18 In Australia the behaviour of pharmacists is guided by the Pharmaceutical Society of Australia’s Code of Professional Conduct (PSACPC).7 Pharmacists sell CAMs in pharmacies that does give credibility to CAMs and to some extent promote their usage.   Also, pharmacists are in a unique position to influence the sale of certain products. For example, CAMs are used by 60 to 80% of oncology patients. According to the British Columbia Cancer Society the psychosocial needs of patients including ‘increased anxiety, need for information, maintenance of a sense of hope, a sense of control, negative experience with conventional medicine, and perceived holistic nature of complementary medicine,’ is the reason for the high percent of people using the medicine and not the availability of the product in pharmacies.19 Pharmacists don’t need to promote these products as psychosocial needs are very powerful and patients are clamouring for these medications in increasing numbers. Although the pharmacy is a business, business objectives wouldn’t necessarily suffer, as knowledgeable and honest patient counselli ng plays an important role in customer satisfaction and thus profitability. An unsatisfied customer would certainly seek another pharmacy.20 These satisfied customers will keep coming back to the pharmacy not just for CAMs but for prescription and personal products as well. This is a win-win situation for both the customer and the pharmacist who now has the opportunity to play an active role in the health of the patient as well as make a decent living. It is the pharmacist who provides the factual advice for patients who seek out these products. Through professionalism this temptation to take advantage of this behaviour is easily removed. Pharmacists develop close relationships with their customers by taking time to talk about medications. Professional orientation happens because patient counselling of all medications including CAMs is at the cornerstone of ethical pharmacy practice and high quality care. As previously stated, the pharmacist’s role in counselling in the use o f CAMs is the most effective in ensuring the health and safety of patients.   When counselling patients, pharmacists follow the PSACPC. By following the PSACPC pharmacists remain in the scope of their practice, are covered for malpractice liability for negligent care and for informed consent issues, and foremost, ensure the health and well-being of clients and the Australian community. Under the 9 key principles of PSACPC, counselling advice for CAM usage is about adhering to the principles of evidence based medicine and critically examining and honestly informing patients of unproven medications and therapies. Pharmacists must also respect the beliefs and judgements of patients and other health professionals while regarding the patient’s autonomy to make decisions regarding their own treatment but at the same time offering guidance and advice based on evidence-based information.21  Ã‚   Thus, when a pharmacist gives advice on the use of Cams based on PSACPC guidelines after considering clinical and patient factors there may be commercial benefits but they do not necessarily compromise the quality of the recommendations. In pharmacy, ethics and profit can and do exist without conflict in the sale of all products.   Duty of care regarding informed consent As outlined above a majority number of Australians are using and want to use CAMs. It is therefore the duty of pharmacists to discuss these treatments with their patients.22 A study in the US found almost three-quarters of the pharmacists surveyed worked in stores where herbal medicines were sold.23 Almost half of the pharmacists agreed with the statement, ‘herbal medicines are not accepted by the majority of my colleagues’ and only a quarter agreed with the statement ‘herbs are efficacious’.24 25 It can be seen that most pharmacists don’t believe in the products so recommending them is difficult. But, they have an ethical obligation to adhere to the PSACPC and respect the autonomy and dignity of the patient to make informed decisions.21 Once the pharmacist has disclosed and openly discussed the different treatment options his or her ethical obligation has been fulfilled. In the United States this is taken one step further.   It is a legal obligatio n for practioners to disclose information for CAMs if they are generally accepted within the medical community. Failure to do so can result in legal action.26 Liability in referring to CAMs Liability issues are new territory for pharmacists recommending CAMs to patients. Homeopathy, for example, is completely contradictory to the principles of modern pharmacology. The incompatibility of homeopathic paradigms with all of basic science must be taken into consideration.22   Keeping in line with the PSACPC, pharmacists cannot ethically recommend a product or service to which they know there is no evidence to support its use, and is not in the best interest in the health and well being of the patient or community. In Canada, The Pharmacy Code of Ethics requires pharmacists to never knowingly provide any products which are not good quality.27   In the United States medical practitioners can be held liable for referring patients to a CAM practitioner if they â€Å"should have known† the CAM practitioner might be â€Å"incompetent†. This shows that medical professionals are not just ethically but legally responsible for protecting patients from inferior medical treatments.28 CAM practitioners argue that their treatments are holistic and some of the therapeutic benefits are unmeasurable. Because western medicine supports evidence based on quantifiable outcomes the two doctrines of practise often clash. It is very difficult to compare the s piritual healing power of CAMs to the physical healing of western medicine.28 As long as the CAM treatment is not interfering with a patient’s level of care, there is no reason to discredit a potential treatment that may make a patient ‘feel’ better. An honest answer to the efficacy of a specific CAM and reporting that some people say it makes them feel better is the best course of action.     Further compounding the issue is the training level of the CAM providers. Most are not ‘health care professionals’ and have inadequate understating of biology, pharmacology, patho-physiology, and other sciences that govern western medicine. Since pharmacists cannot ethically refer a patient for a treatment that they believe may affect their health or wellbeing the ethical dilemma of whether to recommend this option is exacerbated. Although, a recent Canadian study reported only 2% of pharmacists felt they had adequate information about complementary and alternative health care, they are still better suited than CAMs to provide information on the prodcuts.10 A pharmacists guidance is based on principles 1 and 8 of the (PSACPC), advising patient of the scientific evidence available while still respecting their autonomy.28 Where CAM providers have no such code of ethics. Conclusion This paper examined the background issues associated with complementary and alternative medicines (CAMs) and the associated risks and benefits that go along with them. Additionally, the pharmacists’ role in providing CAMs was discussed. The many ethical issues, including profit, although seemingly complex can and should be negotiated using the PSACPC guidelines. The introduction and sale of CAMs have not changed the pharmacist’s code of ethics where the patient’s well-being and health remains the focus. As CAMs are becoming more popular and accepted by the public, pharmacists need to have a high level of understanding of the many issues associated with them. The ethical issues pharmacists face daily are apparently being handled appropriately according the literature cited, and based on the public’s perception of pharmacists being one of the most trusted health professionals.

Nature Versus Nurture: Both Play a Role in Development Essay -- child

Nature versus nurture is a commonly debated topic in the scientific world. For example were all child molesters abused as children themselves or are their genes or other factors to blame for their bad decisions? Genes seem to determine much about children, such as eye color and height, but do they also determine behavior and overall health, or is the environment the children were raised in to blame? For example, when a child is misbehaving, is it the parents responsibility to take the blame for their offspring's behavior due to how they have chosen to raise their son or daughter, or is the child's genetic makeup to blame for their faults? Can a child's environment override the genes a child is born with? Mischievous children's genes and environment are both to blame for their actions. Just because a child sees his or her parents invest their time in drugs or alcohol does not make the child themselves end up in the same situation proving that environment is not the only determining factor in a child's behavior. Genetics play an important role as well. The environment a child is ...

Investment and Market Risk Premium

Cost of Capital at Ameritrade Day 1 1. What factors should Ameritrade management consider when evaluating the proposed advertising program and technology upgrades? Why? -They should see how revenues have changed after adopting the new ad program and technology upgrades -They need to see ROI for their investments over time 2. How can the Capital Asset Pricing Model be used to estimate the cost of capital (required return) for calculating the net present value of a project's cash flows? it will help us determine the Cost of capital or discount rate which we can use to calculate NPV, in other terms the numerator will never change (FCF), only the denominator will based on the cost of capital3. What is the estimate of the risk-free rate that should be employed in calculating the cost of capiual for Ameritrade's proposed investment? – the risk free rate should be the T-bills rate or the average annualized total annual returns on US government securities = 3. %. In my opinion, we sho uld use the risk-free rate equal to yield of 20-year US government securities, because it is long-term capital investment. We may use 30-year rate, but we are investing in technology, and concerning the speed of technological enhancements, 20-year rate is optimal. So it is 6,69% 4. What is the estimate of the market risk premium that should be employed in calculating the cost of capital for Ameritrade's proposed investment? Market Risk PremiumThree distinct concepts are part of market risk premium: 1) Required market risk premium: the return of a portfolio over the risk-free rate (such as that of treasury bonds ) required by an investor; 2) Historical market risk premium: the historical differential return of the market over treasury bonds; and 3) Expected market risk premium: the expected differential return of the market over treasury bonds. Also called equity premium, market premium and risk premium.Market Risk Premium = Expected Return of the Market – Risk-Free Rate The e xpected return of the market can be based on the S;P 500, for example, while the risk-free rate is often based on the current returns of treasury bonds. First to find the Expected Return of the market, from Exhibit 6, We take the aggregate stock market and multiply by 12: = 15. 71% The Risk-free rate is 3. 8% =;gt; The market risk premium= 15. 7 – 3. 8 = 11. 9% (That is why we may use the difference between US Government Securities rate (6,69%)and historical Large Company Stocks annual returns.But we have 2 numbers: during1950-96 and 1929-96. The difference between them is 1,3%. I think that we should useâ€Å" younger† value of 14%, because the years 1930-1949, of course, were under market economy, but at the same time there were not so stable laws, a Second World War passed, many companies at that time worked for government orders, so this number may be a bit out of overall tendencies. ) 5. In principle, how would one go about determining beta for purposes of calcula ting the cost of capital for Ameritrade's proposed investment?TO calculate Beta for cost of capital, or asset beta: We need to find first the Equity Beta = by regressing stock returns over market returns and it will then be the slope. We also need to calculate the market value of the equity of the firm which is the price per share multiplied by the total number of shares outstanding (see attached notes) A cost of capital is a weighted average of the cost of debt and equity. Likewise, the asset beta is the weighted average betas of debt and equity. We use market value proportions of debt and equity (see CAPM, p. 476). Ba = (D/D+E)BetaD+ (E/D+E)BetaEIt is common to assume that debt has no relationship to market risk; that BetaD=0 Empirical studies of corporate debt returns suggest it would be better to assign some market-related risk to corporate debt; and use estimates ranging from 0. 20 to 0. 30. To get BetaE, the equity beta for Ameritrade, we would normally run a regression of equ ity returns on stock market returns. That is, we would estimate the slope of the line that best fits: Unfortunately, Ameritrade had their IPO (Initial Purchase Offer) in March of 1997, so there is not enough data at the time of the case to calculate a reliable beta estimate.So instead, we will look at comparable firms. Firms in the same industry pursuing the same types of projects will have the same sorts of risks, thus their asset betas will be approximately the same. The returns we calculate for these firms, based on stock price movement, dividends, and stock splits, are their equity betas. These are influenced by the degree of leverage each company is using (recall that higher leverage leads to higher ROE, EPS and DPS, but also leads to greater variability in earnings).Knowing the amount of debt in their capital structures (at market values), we can calculate the asset beta for each comparable firm. Then we will average these to use as a proxy for Ameritrade’s asset beta N ote: An agent that mediates sales and exchanges between securities buyers and sellers at even lower commission rates than those offered by a regular discount broker . As one might expect, deep discount brokers also provide fewer services to clients than standard brokers; such brokers typically provide little more than the fulfillment of stock and option trades, charging a flat fee for each.The problem that must be overcome in determining the implementation decision is the uncertainty of the cost of capital. Other Methods of Estimating Cost of Equity Capital: †¢The EP Method r = EPS / Stock Price †¢The Constant Growth (Gordon) Model r = DIV1 / P 0 + g compute g from earnings, dividend, or cash flow growth or use the sustainable growth estimate ? Equity Betas, the relationship of a given equity’s risk to that of the larger market, reflects two kinds of risk –The risk of the business itself –The risk that the debt a business has will prevent cash flow to equity ?We can de-lever these equity betas to strip out financial risk associated with leverage and find the implied beta for the business itself (asset beta) –Asset beta measures the business risk only and does not change with capital structure ? Often, the best way to estimate a forward looking asset beta for a company is to take a median of its industry peers asset betas (historically calculated) since one-time company events in the past will be averaged out ? We can then find the equity beta for the company by re-levering the industry asset beta to the target debt / cap ratio of the company ?Exhibit 4 provides various choices of comparable firms. Which firms do you recommend as the appropriate benchmarks for evaluating the risk of Ameritrade’s planned advertising and technology investments? Determine the betas for these firms. Let us agree that Charles Schwab is a comparable firm. Their price changes, dividends,and stock split information for 1992-1996 is in Exhibi t 5. If there were no stock split, thereturn, compared to the previous period, is given by: For example, if the price the previous period was $100, then wentup to $104, and in addition had a dividend of $8, the return would be +0. 12, or 12%.In ashort time period, the returns will be much closer to 0. If there is an X for y stock split, use the formula: Copy the Return values into Exhibit 6 alongside the appropriate dates, then regress theSchwab returns against the value-weighted NYSE returns for the same period. The slopeof the line is the equity beta. Do this for the other comparable firms. Calculate the asset betas using the formula inquestion 5 (twice, once with Beta D = 0 and once with 25. 0). Average the results. This should be a good estimate of Ameritrade’s asset beta. Finally, put these results back into the equation in #2 to estimate Ameritrade’s cost of capital

Comparing Tekakwitha s Biographers Paint A Completely...

Tekakwitha’s biographers paint her in a completely pious life. She maintained perpetual virginity, renounced any intention of marrying, was adept at acts of self-immolation when repenting, and above all was a quiet and â€Å"behind-the-scenes† kind of woman. â€Å"As a child, the Jesuits relate, Catherine was shy, retiring, and good-natured [†¦] [and this] led her to shun social gatherings† (Greer 32). Apparently, a degree of social introversion and slightly abnormal behaviour are important criterion for an individual who is being evaluated for canonization. It is no doubt that Chauchetià ¨re and Cholenec see Catherine as fitting enough to analyze for this position of possible sainthood, but they actually do a disservice by not being completely accurate. In reality, according to Greer, Catherine was much more involved in her Mohawk community. This is an aspect where Greer’s account shines. He argues that the idea of Tekakwitha having the behaviour of an outcast seems â€Å"implausible† due to conflicting reports from many other Europeans (32). Women in the Mohawk community were â€Å"regard[ed] as the principal support of their families† but Greer goes on to explain that in earlier accounts, the Jesuits only mention Tekakwitha’s female relatives in passing, which is essentially problematic when historical accuracy is of such importance in hagiography (32-33). The recurring theme of paganism does to some extent explain why Chauchetià ¨re and Cholenec had to slightly alter their written accounts of