A threat to patient safety? Meet the pharmacist prescriber and the GP who trained her
Black holes of information in the political debates on healthcare are common — one has been pharmacist prescribing.
Here for the first time, we speak not only to a pharmacist now prescribing under Queensland’s program but also to the GP who trained and supervised her.
Jess Burrey, a pharmacist in Emerald, was accredited as a prescriber by James Cook University in late 2024.
She is currently consulting and prescribing for patients for conditions ranging from acute otitis media to moderate acne and impetigo.
Her supervisor was former ACRRM president, Associate Professor Ewen McPhee.
So how are pharmacists being taught? How are the complexities of differential diagnoses dealt with? Has the reality of diagnosing and prescribing surprised pharmacists?
And in the view of Dr McPhee, at what level is Ms Burrey now operating as a clinician?
Find out here.
AusDoc: Jess, can you describe your training as a prescriber under the program? What did it involve?
Jess Burrey: I have been prescribing for almost 18 months now independently. Ewen was my designated prescriber and supervisor throughout my training.
During that time, I would spend half a day or a day every week at his practice. Initially, at least, it involved sitting in on consults and observing.
And then we progressed to the point where I would probably see every second patient. I would do the history-taking and make an assessment about whether it was within my scope.
If it was, I would perform a physical examination and then hand over to Ewen and say, ‘Okay, this is what we’ve got.’
There were times where I did not know what we had, did not know what to do next.
In terms of learning the examination skills, I would say, ‘I think I heard this or that, but I’m not really sure.’
So then I’d have to do it again while Ewen was there to ensure that we’re doing it properly and thoroughly and building the skills.
Because obviously you don’t know what a dodgy heart or dodgy lungs sound like until you’ve done lots and lots of the examinations, and you don’t know if you only practise on well patients.
AusDoc: How was Ewen as a mentor?
Jess: Ewen provides very clear direction, but he also kind of leaves you out a little bit in the wilderness to figure it out, and will then come in and save you at the end.
It’s a way to do it, a way to explain it.
AusDoc: Ewen, you’ve supervised and mentored hundreds of doctors. Were there challenges for you?
Ewen: Yes and no. Jess was the first of the pharmacy cohort that we’ve been associated with.
I guess the challenge for me is to understand how a pharmacist thinks compared with how a doctor thinks, because they are very different insofar as risk assessment, roles and responsibilities.
The most important thing, and I think Jess would agree, was the rigour of clinical reasoning, about asking ‘the why’ behind the presentation and being able to make sure you haven’t missed the elephant in the room.
You need to have a safety net. Safety is the foundation. Whatever we’ve got to do, it’s got to be safe.
You need confidence that the clinicians are practising at the top of scope, but they’re not … going off the reservation.
AusDoc: When this pilot has been discussed, critics were meant to be reassured by declarations that treatments would be protocol driven.
Pharmacists would be doing nothing more than following a list of instructions and referring whenever things got complicated.
But it doesn’t sound like that at all in terms of your training.
Ewen: It can’t be a protocol process because what we’re talking about is clinical consultations and our intent is to help the pharmacist to realise that they don’t know what they don’t know.
The only way you’re going to get people to reflect upon their training and reflect upon their knowledge is to put them in a situation where they … realise they don’t have a set of skills to be able to proceed.
So it sounds cruel to say I threw Jess in at the deep end. Well, we didn’t throw her in at the start because I was sitting in with doctors and registrars and saying, ‘Look at how a medical consultation goes.’
But at some point when we give Jess a number of patients, we expect her to know the problem, we expect a management plan, we expect some degree of structure.
And then we can sit together and deconstruct the consult and look at where skills development needs to happen.
So I don’t see how you could take a protocol approach.
AusDoc: Jess, to what extent are your patients booking appointments?
Jess: We do take appointments, but I would say probably 90-95% of our consultations are a walk-in or opportunistic consultation based on a person presenting to the pharmacy for standard pharmacy treatment.
You know, someone’s come in because their child has an earache and they want some pain relief. And now I say, ‘Oh, well, I actually can have a look in their ear. We can do a consultation.’
AusDoc: What presentations do you see and what information do you have access to at the time of the consult?
Jess: I have the extent of what is on a patient’s My Health Record. I also have access to The Viewer [Queensland’s patient information portal for the state’s public health services].
That being said, I have not had to use it very often for emergency presentation information. But it is much the same as if a patient goes to a GP they’ve never seen before.
It’s the My Health Record as the primary source.
In terms of presentations it’s most of the conditions covered by the program (see box below for list) but in our region I see a lot of ear infections, impetigo, shingles, contraceptive consultations.
And yes, all the consults are in a private fit-for-purpose consult room much the same as a GP consult room.
AusDoc: And how many consults on a typical day?
Jess: It is hit and miss. On my busiest day, I would probably see 8-10 patients. And then some days that would be none. But we haven’t really advertised per se that we have the service.
In terms of the length of the consults, I’d say the majority, depending on the presentation, probably fall into a standard 10-20-minute consultation.
Very rarely are they brief.
AusDoc: What was the biggest surprise to you in terms of what you expected prescribing to be about?
Jess: I would say how much I didn’t know. I came in thinking, ‘I often see impetigo or shingles in the pharmacy, this will be easy.’
It was far from easy. I definitely underestimated the time I would need to complete the training.
It was about deepening my knowledge of the conditions beyond what I had been taught as a pharmacist. I’m 20 years post-graduation. It was a long time ago.
It was about developing clinical reasoning and the necessary change in mindset that demanded.
As a pharmacist over the years, I have done lots of things. I’ve delivered health coaching through My Health for Life, I’ve had base-level skills in motivational interviewing and undertaking histories and things like that.
But then to bring it all together in a flow during a consultation took some adjustment for me. I probably underestimated how much adjustment that would take.
AusDoc: So you agree you were not doing something that could be protocol driven?
Jess: I would say that none of it is protocol driven.
There are some very clear clinical guidelines to follow that tell us this is definitely outside our scope — you must refer.
I felt they were helpful as a new clinician. I knew very clearly where my lane is and what’s safe and what’s not safe for me to be managing.
So you know if X or Y comes up, I’ve got to involve somebody else.
But it is definitely not a tick and flick exercise. I have really developed my clinical reasoning over time.
I don’t know whether it’s just me, but I have so many patients who are not what you’re expecting.
So yes, now I ask about the elephant in the room. If it were protocol-based, I definitely think a lot more things would be missed.
Ewen: In the training, we are trying to raise awareness of the things you cannot afford to miss.
An ear infection? We don’t want to miss a mastoiditis, we don’t want to miss a middle cerebral tumour.
You can’t teach everybody everything, but you can give people sufficient awareness of their own scope and also that sense of discomfort which starts to come in when they need to think, ‘Do I need a second opinion?’
AusDoc: Jess, the scripts are not covered by the PBS. But what consult fees do you charge patients?
Jess: It’s all time-based on the length of consult. The chronic condition program run by Queensland Health is aligned to the bulk-billing fees, although I know that things have changed recently (see box below).
Given our location and the cost of our wages, we do charge a little bit higher than those fees for anything that’s outside the program at the moment, just to make sure that we’re not haemorrhaging money in trying to improve the health outcomes.
Consult fees for the Pharmacy Chronic Conditions Management Pilot
| Time | Fee | |
| Brief consult | <10 mins | $19.50 |
| Standard consult | Between 10 and 20 mins | $36.70 |
| Long consult | >20 mins | $70.50 |
These fees were originally paid out-of-pocket by the patient.
However, since 1 January, they have been covered by not-for profit indemnity provider Pharmaceutical Defence Limited.
AusDoc: Is any of this economically viable for the pharmacy?
Jess: I think it’s important to recognise that this was never about us making lots of money.
This is about making sure that we’re giving patients access to care and improving health outcomes. It was about building collaboration within the health system.
I would say as a business owner, outside of my role as a clinician, this needs to be financially sustainable to operate.
At present, with the cost of training and changes to our practices, we’ve not seen any return on investment at this stage.
Editor’s note: Ms Burrey is on the Central Queensland branch committee of the Pharmacy Guild of Australia.
AusDoc: After a consult, what communication takes place with the patient’s GP?
Jess: There is communication where the patient has a regular GP. But in many cases, I’m seeing patients who don’t have a regular GP who have been accessing telehealth providers or using instant scripts and things like that.
So in those cases, we provide a summary to give to a GP when they next present.
Anyone who has a local GP, we’ll send a consult summary.
But I would say the vast majority of patients I have seen — and I practise across both the Emerald and Marian up in the Pioneer Valley near Mackay — don’t have a GP that they are seeing regularly.
AusDoc: Are you using AI scribes to generate medical notes?
Jess: Personally, I am not. I’ve spoken a number of times with Ewen about the programs and also with the [pharmacist] prescribers coming behind me in my team.
I advise them that they’re not to use AI until they can confidently write their own clinical notes and transcripts.
Because AI is great, but if you cannot clinically or critically analyse what it’s saying, then it’s an issue. I can see that it would be very time-efficient for me to use it. I still feel like I need to build those muscles.
AusDoc: Have your indemnity premiums gone up?
Jess: We have quite extensive indemnity insurance as it stands. I have spoken with both of my insurers to discuss my increased scope and at this stage the level of cover I hold has been adequate.
AusDoc: Do you think there are elements of the program that need changing? Would you want to expand it?
Jess: I understand the chronic conditions are being reviewed. The other elements are just inconsistencies. For instance, I can treat an asthmatic for their asthma if they have COPD, but I can’t treat someone with COPD for their COPD if they’re an asthmatic.
There are also some silly anomalies where you are given a hard referral point, which was creating issues for patients when they can’t access a GP immediately.
There are some quite firm guidelines around irregular bleeding and PCOS diagnoses and referrals. It was hard and fast, so you just can’t treat.
But if somebody’s still under the continuing management of their GP or their specialist, it should allow us to give them continuing therapy and make sure that they’re being looked after.
Can we do more over time? Yes, I think that there’s a possibility for us to assist.
AusDoc: I know Jess is sitting here, so forgive me, Jess, but Ewen, can I ask about the level Jess is operating at?
Ewen: It is a straightforward answer. Jess would be consistent with a nurse practitioner or a physician’s assistant.
She’s able to practise independently within the scope she is trained for, with a direct relationship to a clinical service should she need it.
AusDoc: Is the fact that Jess has taken on this scope reducing your workload, which is one of the reasons given for the original prescribing pilot?
Ewen: It’s not going to reduce our workload.
Those sorts of commentaries are just magical thinking from people who are just trying to justify something that sounds simple to people.
The medical environment is changing. We have to embrace other providers who are well trained, and there’s no reason why they shouldn’t be doing this work.
There is a lack of access to specialists, and there are prolonged waiting lists for public hospital consultations.
I’ve got people sitting on waiting lists for four years now to see a physician.
Well, who’s had to manage their medical problem during that time — it’s the GP.
The complexity of what we do is rapidly increasing. I’m doing the work of an internal medicine specialist, and I say that not tongue-in-cheek because often our consults are taking half an hour, an hour to go through complex issues which have been neglected over several years.
We’ve recently embarked upon establishing an Aboriginal health service in our region. Aboriginal people have not been able to see a clinician in 10-15 years because they can’t afford it.
This is where I probably diverge from the popular opinion: having pharmacists and other clinicians being able to support us, underpinned by really great communication and trust, is a game changer for me.
AusDoc: What impact has it had on you in terms of your job satisfaction, Jess?
Jess: You would think after 20 years as a pharmacist that I would be starting to get a little jaded, but I actually love being a pharmacist.
However, this has definitely invigorated my career.
It has taken away a lot of frustration for me, where we see patients, then we have to go through the process to send them away for quite simple things.
And then we get them back two hours later, or sometimes two days later, with scripts that I know I’m able to provide.
And it’s actually triggered … me to go and do a lot more learning. I have taken further interest in women’s health, and I’m doing more upskilling outside of the formal CPD requirements of being a prescribing pharmacist.
It’s a new life, a new lease on life for me.
AusDoc: But have you considered retraining as a GP?
Jess: Do I want to be a GP? No, thank you.
AusDoc: Any reason why not?
Jess: I’m very, very happy as a pharmacist and the ability to be able to make an impact on patients, you know, within my scope.
And, you know, I had a childhood ambition, maybe my parents’ ambition, to become a GP at one point in my life.
But I’m very happy with the path that I chose, and I’m not particularly keen to go and do that.
Sorry, Ewen.
This Q&A was edited for clarity and length.
Pharmacist prescribing in Queensland
What training do pharmacists undergo?
According to the Pharmacy Guild of Australia, there are now 403 pharmacists who can prescribe in Queensland.
Pharmacists can become accredited prescribers for the Queensland Community Pharmacy Chronic Conditions Management Pilot through one of two courses.
There is a graduate certificate program with James Cook University or a training program with the Pharmaceutical Society of Australia, both of which take at least 12 months.
Both go over the frameworks and guidelines involved, technical details of assessing patients, and the management of relevant acute and chronic conditions.
Both programs require students to study under a designated prescriber (potentially a GP or nurse practitioner) — James Cook University requires that students do 120 hours, while the Pharmaceutical Society of Australia requires the student complete a minimum of six case studies.
Students must also complete an Objective Structured Clinical Examination before graduating.
There is also a training program allowing pharmacists to prescribe hormonal contraception, which takes only 5-6 hours to complete with the Australasian College of Pharmacy.
What is the scope of pharmacist prescribing?
Pharmacist prescribers in Queensland can autonomously prescribe medication, including S4 drugs, for:
Skin and infections
- Impetigo
- Herpes zoster
- Mild-moderate atopic dermatitis
- Mild-moderate acne
- Acute exacerbations of mild plaque psoriasis
- Acute minor wound management
ENT
- Allergic and non-allergic rhinitis
- Acute diffuse otitis externa and acute otitis media
Gastrointestinal
- GORD
- Acute nausea and vomiting
Musculoskeletal
- Acute mild musculoskeletal pain and inflammation
Women’s health
- Hormonal contraception
Others
- Smoking cessation
- Travel health
- Oral health screening and fluoride application
- Management of overweight and obesity
Chronic disease management programs
- Cardiovascular Disease Risk Reduction Program for type 2 diabetes, hypertension and dyslipidaemia
- Improved Asthma (and exercise-induced bronchoconstriction) Symptom Control Program
- COPD Monitoring Program
