Let me say at the outset that I love my pharmacist, Calvin, who is a wealth of knowledge. And, often when I have phoned in a prescription for a patient, the pharmacist to whom I spoke has warned me about a potential drug interaction that I didn’t know about and been able to answer my questions about how best to dose a drug. But some months ago, I had an interaction with a pharmacist that stunned me. Here’s the back story: We use a lot of drugs “off label” in wound care, particularly for pyoderma gangrenosum. There’s not much we all haven’t tried for PG (sometimes with good success), including ocular cyclosporin — and for peristomal PG, ground up prednisone tablets. Truth be told, the primary use for many drugs is an “off label” indication because after it was approved by the FDA, the drug turned out to have better uses than the indication for which it was originally developed. It is true that some pharmacy drug plans can decide not to PAY for the off label use of a drug, but it is entirely within the scope of medical practice for a doctor to prescribe an FDA approved drug in an off label manner.
Here’s what shocked me. The pharmacist told me that she would not dispense the medication I ordered (in this case ocular cyclosporin) for topical use on a wound. Her reason for refusing was NOT because the pharmacy plan denied it, and not because it might be dangerous since anything approved to put in your EYE can be used on an open wound. The pharmacist refused to fill the prescription because the drug “wasn’t proven to work in pyoderma.” After that, our conversation went downhill with me explaining her role as a pharmacist and my role as a doctor and the fact that currently, NOTHING was approved specifically for PG. I hung up thinking, “What just happened? When did pharmacists start practicing medicine?” It turns out my experience was not unique.
The American Medical Association (AMA) has had a lot of reports like this and recently released a statement about it. The AMA’s involvement began when a New Jersey ophthalmologist reported that a pharmacist had refused to fill a prescription because it was “outside the prescriber’s specialty.” He had ordered a cream to treat a patient’s rosacea, which can increase the risk of blepharitis. Investigation revealed that in New Jersey, other ophthalmologists, as well as anesthesiologists were encountering instances in which pharmacists appeared to substitute their judgment for the physician’s in refusing to fill orders for sedatives, anxiolytics, or dermatologic agents.
At the 2025 AMA meeting, The American Academy of Ophthalmology introduced a resolution targeting the issue which states that, “Such refusals contradict American Medical Association policy opposing pharmacists’ authority to initiate, modify or substitute medications outside a physician’s explicit direction, and amount to inappropriate intrusion into the practice of medicine.” The AMA resolution goes on to state: “Pharmacists are not trained or licensed to make medical diagnoses, and their scope of practice does not include the authority to override a physician’s clinical judgment or determine a patient’s treatment plan . . .These denials disrupt patient care, compromise safety, delay medically necessary treatment and may create liability and access issues, particularly for patients with urgent or chronic conditions.” To address the issue, delegates at the 2025 Annual Meeting directed the AMA to study the matter and its impact on patients and work with state medical boards and pharmacy boards on it. A report is likely to be issued at the 2026 AMA Annual Meeting in June. The AMA considers this behavior “scope creep,” and is fighting back both in Congress and at the state level. The AMA has also released informational material about the difference between pharmacists and physicians.
Let me know if you have had a similar experience when you tried to prescribe something for a wound care patient.
–Caroline
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
