EDITORIAL
Nos injerimos?
Are we meddling?
esde febrero de 1998 la Organizacin
D S
Mdica Colegial (OMC) viene planteando
la acusacin de "injerencia profesional"
respecto de la prctica de la Atencin
Farmacutica que desde esta revista y
esta Fundacin tratamos de impulsar.
Con fecha 27 de marzo de 2000, la
OMC ha difundido a todos los colegiados
mdicos de Espaa dos documentos, el
primero de los cuales titula "Lmites de
las funciones profesionales de mdicos y farmacuti-
cos"; en el mismo se establecen los lmites de nues-
tras competencias profesionales de forma unilateral,
sin acuerdo previo con ninguna entidad representa-
tiva de los farmacuticos. El documento pone en
cuestin que nuestras competencias profesionales
puedan ir ms all de la mera dispensacin de los
medicamentos por nosotros custodiados. A la OMC
le inquieta la indefinicin legal de la Ley de 26 de
abril de 1997 sobre Regulacin de Servicios de las
Oficinas de Farmacia que, a su juicio, facilita la "intro-
misin de la profesin farmacutica en el terreno
asistencial del mdico".
Por otra par te, ejemplos de casos simulados utili-
zados en algunos cursos de Atencin Farmacutica
a distancia, con el objetivo de ensear Farmacologa
y Farmacoterapia, han ocasionado que en el VII
Congreso Nacional de Medicina General, celebrado
en Granada, el Dr. Solla, representante espaol en la
Unin Europea de Mdicos Generales, los considere
un claro ejemplo de intrusismo. En la secuencia de
actividades considerada por algunos como Atencin
Farmacutica, se somete al enfermo a una explora-
cin fsica, se solicitan pruebas diagnsticas y se
establecen planes teraputicos incluyendo o no
incluyendo medicamentos. Si estas actividades cons-
tituyesen el proceso propio de nuestra competencia
profesional, la Atencin Farmacutica no sera ms
que una mala imitacin del proceso de Atencin
Mdica.
Ahora bien, no realizar exploraciones fsicas no
quiere decir que los farmacuticos tengan que
taparse los ojos para atender a los que usan medi-
camentos bajo su competencia; no solicitar pruebas
diagnsticas no puede conver tirse en "acceso prohi-
bido" a las cifras de analticas que suponen control
de parmetros en relacin con el buen o mal uso
de medicamentos; no establecer planes teraputicos
no puede impedir el acuerdo entre farmacutico y
paciente de planes temporales para mejorar la utili-
ince Februar y 1998 the Spanish Medical
Association has posed the accusation of "pro-
fessional meddling" with respect to
Pharmaceutical Care which from this journal
and Foundation we are trying to encourage.
On March 27th 2000, this Association emit-
ted to all medical associate members in Spain
two documents, the first of which titled "The
limits of physicians' and pharmacists' professio-
nal functions"; established the limits of our pro-
fessional competence in a unilateral way, with no pre-
vious agreement with any entity representative of the
pharmacists. The document questions our professional
competence to be able to go further than the mere
dispensation of medicines in our custody. This
Association is worried about the legal indefinition of
the Law of April 26th 1997 of regulation of community
pharmacy services, which according to their judgement
facilitates the "interference of the pharmaceutical pro-
fession in the assistential terrain of the physician".
On the other hand, examples of simulated cases in
some Pharmaceutical Care distance courses, with the
object of teaching pharmacology and pharmacothe-
rapy have occasioned that in the VII National Congress
of General Medicine, celebrated in Granada, Dr Solla,
the Spanish representative of General Practitioners in
the European Union, considered them a clear example
of interference. In the sequence of activities considered
by some as Pharmaceutical Care, the patient was sub-
mitted to a physical exploration, diagnostic tests were
requested, and therapeutic plans were established
including or not medicines. If these activities constitute
the professional competence of our own process, then
Pharmaceutical Care would be nothing but a poor imi-
tation of the medical process.
However, not to carry out physical exploration, does
not mean that the pharmacists have to be blindfolded
themselves so as to attend those who use medicines
under their competence; Not to request laborator y
tests should not become "entrance forbidden" to analy-
tic figures which suppose control over the parameters
in relation to the good or bad use of medicines; Not to
establish therapeutic plans must not impede agree-
ment between the pharmacist and the patient of tem-
poral plans in order to improve the use or compliance
of certain medicines and to be able to test them.
This editorial would like to point to the possible
minimum agreement between a general practitioner
and a community pharmacist if we want to obtain a)
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
poder comprobarlo.
Este editorial quiere sealar el acuerdo de mni-
mos posible entre un mdico general y un farma-
cutico comunitario si queremos conseguir : a) un
uso efectivo y saludable de los medicamentos y b)
el aprovechamiento ms eficiente de los profesiona-
les sanitarios disponibles.
El acuerdo ha tenido la siguiente reflexin previa
por par te del mdico general:
"Eso de la injerencia me ha hecho trabajar. La
palabra es fea y produce rechazo. Me pregunto si
tiene algo que ver con ingerir. Me asomo al diccionario
y el til mamotreto me pone trabas. Es cuestin de
espacio. Muchas palabras. La solucin fue poner la
letra ms pequea. Los aos no pasan en balde y
necesito ayuda de las gafas. Aun as tengo que esfor-
zarme.
La vista me la grada una amiga oftalmlogo. En
su sala de espera hay un cartel que expresa clara y
explcitamente que el oftalmlogo es el nico autoriza-
do para prescribir e instilar colirios. Me afecta directa-
mente pero nunca le coment nada. Dudo de su valor
legal y mucho ms de su veracidad. Despus de que
su auxiliar me regase los ojos ella me hizo la gradua-
cin.
Esta misma semana, por la tarde, un hombre acu-
di al Centro de Salud. Le haban prescrito un colirio.
Vive solo. No es capaz de auto-instilarse. Su hermana
no est en casa. Se las echo yo y, segn el cartel de mi
amiga, injiero (al menos tanto como su auxiliar). El
hombre se fue agradecido e ignorante de que mi acto
pudiese ser delictivo.
Porque s. Se habla de injerencia, se habla de intru-
sismo. Esto ltimo contemplado en el Cdigo Penal
donde figuran los delitos y convierte en delincuentes a
quienes los practican.
A los mdicos de Atencin Primaria se nos acus
de intrusismo por hacer ciruga menor, toma de citolo-
gas, poner DIU, hacer ecografas, seguir embarazos y
ms cosas que no recuerdo y otras que prefiero no
recordar (se lleg a pedir que los mdicos generales no
tuvieran acceso a las oposiciones de Atencin
Primaria).
Es un problema de pan, no de trabajo. Alguien
cree que lo razonable habra sido mandar a ese hom-
bre a un oftalmlogo? Que levante la mano!
Destacar tanto que yo lo ver desde aqu.
Ahora se abre otro frente. Es que eso de la
Atencin Farmacutica da mucho juego. Cmo un far-
macutico va a tomar una tensin arterial o mirar una
glucemia (y ms interpretarla)? De locos! Y de los
medicamentos? Darse cuenta de interacciones, sobre-
dosificacin, duplicidad, alergias y todos aquellos pro-
blemas relacionados con medicamentos parecen no
ser asunto de nadie. Estas actividades delictivas se
148 Pharm Care Esp 2000; 2: 147-150
most efficient exploitation of the health professionals
available. The agreement had the following prior reflec-
tion by the general practitioner:
"This thing about interference has made me
work. The word is ugly and produces rejection. I ask
myself if it has something to do with ingest1. I take a
look at the dictionary and the whacking great book
shackles me. It's a question of space. Lots of words.
The solution was to make the letters smaller. Time
does not pass in vain and I need help from my glas-
ses. But even then I have to make an effor t.
My sight was tested by an ophthalmologist friend
of mine. In her waiting room there is a sign which
clearly and explicitly expresses that the ophthalmo-
logist is the sole person authorized to prescribe and
instill eye-drops. This affected me directly but I didn't
say anything. I doubt its legal value and even more
so its truthfulness. After her assistant had irrigated
my eyes she gave me the eye test.
This same week, in the afternoon, a man came to
my clinic. He had been prescribed eye-drops. He
lives alone. He is not capable of instilling the eye-
drops himself. His sister isn't at home. I put them in,
and according to my friend's notice, I meddled (at
least as much as her assistant). The man went away
grateful and ignorant of the fact that my act could
be termed criminal.
Because if one talks of interference, one is talking
of meddling. The latter contemplated in the Penal
Code where crimes are to be found and this con-
ver ts those who practice it into delinquents.
We, Primar y care physicians, were accused of
meddling by carrying out minor surgery, the taking
of cervix smears, the emplacing of IUDs, the taking
of echography, the follow up of pregnancies and
many more things which I don't remember and
others I prefer not to (It has got to the point of
asking that general practitioners should not have
access to primary care entrance exams).
This is a problem of bread and not of work. Is
there anybody who believes that the most reasona-
ble thing to do was to have sent that man to the
ophthalmologist?. Put your hand up!. It will stand out
so much I will see it from here.
Now another front has opened up. There is a lot
of play in Pharmaceutical Care. How is a pharmacist
going to take someone's blood pressure or look at
glycemia (let alone interpret it). Madness!. And what
about medicines?. To take notice of interactions, over-
doses, duplicity, allergies and all those drug-related
problems seems to be nobody's business.These crimi-
nal activities are done after the medical consultation
1
Translator note: In Spanish language, meddling and ingest sound very
similar (injerencia and ingesta).
 F. Abal Ferrer et al.
zacin o el cumplimiento de cier tas medicaciones y
poder comprobarlo.
Este editorial quiere sealar el acuerdo de mni-
mos posible entre un mdico general y un farma-
cutico comunitario si queremos conseguir : a) un
uso efectivo y saludable de los medicamentos y b)
el aprovechamiento ms eficiente de los profesiona-
les sanitarios disponibles.
El acuerdo ha tenido la siguiente reflexin previa
por par te del mdico general:
"Eso de la injerencia me ha hecho trabajar. La
palabra es fea y produce rechazo. Me pregunto si
tiene algo que ver con ingerir. Me asomo al diccionario
y el til mamotreto me pone trabas. Es cuestin de
espacio. Muchas palabras. La solucin fue poner la
letra ms pequea. Los aos no pasan en balde y
necesito ayuda de las gafas. Aun as tengo que esfor-
zarme.
La vista me la grada una amiga oftalmlogo. En
su sala de espera hay un cartel que expresa clara y
explcitamente que el oftalmlogo es el nico autoriza-
do para prescribir e instilar colirios. Me afecta directa-
mente pero nunca le coment nada. Dudo de su valor
legal y mucho ms de su veracidad. Despus de que
su auxiliar me regase los ojos ella me hizo la gradua-
cin.
Esta misma semana, por la tarde, un hombre acu-
di al Centro de Salud. Le haban prescrito un colirio.
Vive solo. No es capaz de auto-instilarse. Su hermana
no est en casa. Se las echo yo y, segn el cartel de mi
amiga, injiero (al menos tanto como su auxiliar). El
hombre se fue agradecido e ignorante de que mi acto
pudiese ser delictivo.
Porque s. Se habla de injerencia, se habla de intru-
sismo. Esto ltimo contemplado en el Cdigo Penal
donde figuran los delitos y convierte en delincuentes a
quienes los practican.
A los mdicos de Atencin Primaria se nos acus
de intrusismo por hacer ciruga menor, toma de citolo-
gas, poner DIU, hacer ecografas, seguir embarazos y
ms cosas que no recuerdo y otras que prefiero no
recordar (se lleg a pedir que los mdicos generales no
tuvieran acceso a las oposiciones de Atencin
Primaria).
Es un problema de pan, no de trabajo. Alguien
cree que lo razonable habra sido mandar a ese hom-
bre a un oftalmlogo? Que levante la mano!
Destacar tanto que yo lo ver desde aqu.
Ahora se abre otro frente. Es que eso de la
Atencin Farmacutica da mucho juego. Cmo un far-
macutico va a tomar una tensin arterial o mirar una
glucemia (y ms interpretarla)? De locos! Y de los
medicamentos? Darse cuenta de interacciones, sobre-
dosificacin, duplicidad, alergias y todos aquellos pro-
blemas relacionados con medicamentos parecen no
ser asunto de nadie. Estas actividades delictivas se
148 Pharm Care Esp 2000; 2: 147-150
most efficient exploitation of the health professionals
available. The agreement had the following prior reflec-
tion by the general practitioner:
"This thing about interference has made me
work. The word is ugly and produces rejection. I ask
myself if it has something to do with ingest1. I take a
look at the dictionary and the whacking great book
shackles me. It's a question of space. Lots of words.
The solution was to make the letters smaller. Time
does not pass in vain and I need help from my glas-
ses. But even then I have to make an effor t.
My sight was tested by an ophthalmologist friend
of mine. In her waiting room there is a sign which
clearly and explicitly expresses that the ophthalmo-
logist is the sole person authorized to prescribe and
instill eye-drops. This affected me directly but I didn't
say anything. I doubt its legal value and even more
so its truthfulness. After her assistant had irrigated
my eyes she gave me the eye test.
This same week, in the afternoon, a man came to
my clinic. He had been prescribed eye-drops. He
lives alone. He is not capable of instilling the eye-
drops himself. His sister isn't at home. I put them in,
and according to my friend's notice, I meddled (at
least as much as her assistant). The man went away
grateful and ignorant of the fact that my act could
be termed criminal.
Because if one talks of interference, one is talking
of meddling. The latter contemplated in the Penal
Code where crimes are to be found and this con-
ver ts those who practice it into delinquents.
We, Primar y care physicians, were accused of
meddling by carrying out minor surgery, the taking
of cervix smears, the emplacing of IUDs, the taking
of echography, the follow up of pregnancies and
many more things which I don't remember and
others I prefer not to (It has got to the point of
asking that general practitioners should not have
access to primary care entrance exams).
This is a problem of bread and not of work. Is
there anybody who believes that the most reasona-
ble thing to do was to have sent that man to the
ophthalmologist?. Put your hand up!. It will stand out
so much I will see it from here.
Now another front has opened up. There is a lot
of play in Pharmaceutical Care. How is a pharmacist
going to take someone's blood pressure or look at
glycemia (let alone interpret it). Madness!. And what
about medicines?. To take notice of interactions, over-
doses, duplicity, allergies and all those drug-related
problems seems to be nobody's business.These crimi-
nal activities are done after the medical consultation
1
Translator note: In Spanish language, meddling and ingest sound very
similar (injerencia and ingesta).

hacen despus de la consulta del mdico y si el farma-
cutico no se interpone, interfiere o injiere el paciente
se queda sin una proteccin contra estos problemas.
Las autoridades hacen disponibles a nuestra pres-
cripcin unos medicamentos que se consideran eficaces;
an as, desde el propio ministerio, algunos de ellos son
luego calificados como de utilidad teraputica baja o de
nula innovacin. Puedo entonces dudar a veces de la efi-
cacia de algunos medicamentos, pero no dudo del mal
uso que se hace de ellos y de que, aun siendo la eficacia
menor de la deseada, la efectividad est muy lejos de
ella. Y si ayudamos entre todos a elevarla? con farma-
cuticos que se injieren?
Si para conseguir mayor efectividad del uso de
medicamentos en los pacientes que yo atiendo hay
que hacerse delincuente, dgame usted donde tengo
que apuntarme."
Tras esta reflexin, nos ha sido fcil consensuar
los siguientes puntos mnimos:
Respecto a las "consultas farmacuticas" S, con-
sulta; como existen consultas jurdicas, o de ingenie-
ra o de inversin financiera o de jardinera.o
mdicas. An llamndose todas "consultas" los obje-
tivos que el usuario tiene cuando acude a ellas y los
procedimientos utilizados por el profesional para
resolver las dudas del consultante son diferentes. A
ellas se acude cuando confiamos en que un profe-
sional (que ha adquirido especiales conocimientos
tcnicos en un campo determinado del saber)
puede resolver nuestros problemas o dudas sobre
algo que nos afecta. A la consulta mdica se acude
para que el profesional que sabe de enfermedades y
de cmo tratarlas resuelva qu nos pasa y cmo
arreglarlo. Lgicamente la consulta no se cierra con
la primera visita sino con el eplogo de observar el
resultado del plan teraputico establecido, responsa-
bilidad tan mdica como la de diagnosticar y esta-
blecer la teraputica. A la consulta farmacutica se
acude para que el profesional que sabe de medica-
mentos y de cmo usarlos, nos indique cul de los
medicamentos que tiene en la farmacia puede ser
ms eficaz para controlar la sintomatologa que
tenemos y que nosotros mismos hemos considera-
do banal y susceptible de automedicacin. En esa
situacin hay siempre unas primeras preguntas-filtro
para derivar a la asistencia mdica aquellas consultas
en las que el farmacutico considera que lo que al
ciudadano le parece banal y automedicable, a su jui-
cio no lo es. Por otra par te, los medicamentos a
indicar por el farmacutico son siempre de "no-
prescripcin mdica" y es evidente que conoce
mejor que el resto de los ciudadanos sus indicacio-
nes, eficacia y seguridad.
Respecto al acceso y registro de datos del usua-
rio de medicamentos: Todos los datos de parme-
tros biolgicos, actuales o pasados, que puedan ayu-
Nos injerimos? / Are we meddling?
and if the pharmacist does not interfere or meddle,
the patient has no protection against these problems.
Authorities make available to our prescription
medicines that are considered to be efficacious,
some of which are later qualified as of low thera-
peutic value or of null innovation. So I can someti-
mes doubt the efficacy of some medicines, but don't
doubt the bad use made of them and of which, even
being less the desired efficacy, the effectiveness is far
from it. And what if among us all we elevate it?. With
pharmacists who meddle?.
If in order to obtain a major effectiveness of the
use of medicines in patients that I attend, I have to
become a delinquent, tell me where I have to sign
up."
After this reflection, it has been easy for us to the
following minimum points:
With respect to the "pharmaceutical consultations",
Yes, indeed consult; The same as there exist legal or
engineering, financial investments, or gardening, ... or
physicians consultations. Even though they are all
called consultations the objectives the user has when
he or she visits them and the procedure used by the
professional in order to resolve the consulter's doubts
are different. We visit them when we are confident that
a professional (who has acquired special technical
knowledge in a determined field of learning) can resol-
ve our problems or doubts on something that affects
us. A physician's clinic is visited because the professio-
nal, who knows about illnesses and how to treat them
knows how to fix and resolve what is wrong with us.
Logically the consultation does not end with the first
visit but with the epilogue of observing the result of the
established therapeutic plan, a responsibility as medi-
cal as the diagnosing and establishing of therapy. The
pharmacist's consultation is visited so that the profes-
sional, who knows about medicines and how too use
them, indicated to us which of the medicines in the
pharmacy may be the most efficacious to control the
symptoms we have and which we ourselves have con-
sidered banal and susceptible to self-.medication. In
this situation there are always some primar y filter-
questions to refer those consultations to medical care
that the pharmacist considers that what the individual
considers banal and self-medicable, by his professional
judgement is not so. On the other hand, the medicine
indicated by the pharmacist are always non-prescrip-
tion medicines, and it is evident that he or she knows
better than the rest of the citizens their indications,
efficacy and safety.
With respect to the access and data registration of
medicine users: All the data of biological parameters,
past or modern, that could help the identification of
problems in effectiveness or safety in the use of medi-
cines should be known by the pharmacist. Their records
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
seguridad en el uso de medicamentos deben y pue-
den ser conocidos por el farmacutico. Sus registros
y archivos estarn sometidos a las mismas exigencias
de privacidad y confidencialidad que el resto de la
documentacin clnico-sanitaria.
Respecto a la evaluacin por el farmacutico de
la informacin disponible: Recogida la informacin
que se deriva de los datos y de lo manifestado por
el enfermo o su cuidador, la evaluacin del farma-
cutico versar siempre sobre la posible causalidad
de un modo determinado de usar medicamentos y
la falta de efectividad, la aparicin de toxicidad y la
falta o exceso de indicacin de esos medicamentos
en uso.
Respecto a la decisin de intervenir en el proce-
so de uso de medicamentos por los pacientes/usua-
rios. Evaluada la informacin, la decisin de interve-
nir en el uso de medicamentos con la finalidad de
mejorar los resultados sanitarios, tiene como con-
trapar tida asumir la par te de responsabilidad profe-
sional que corresponda.
La Atencin Farmacutica ha demostrado hasta
el momento disminuir los das de enfermedad en los
pacientes asmticos, rebajar el nmero de hospitali-
zaciones, das de hospitalizacin y recadas por
enfermedad en los pacientes con insuficiencia car-
diaca y con enfermedad coronaria, aumentar el
cumplimiento en los tratamientos con antibiticos,
incluidos los tratamientos antituberculosos, es decir :
interviniendo sobre el uso, se mejora la efectividad
de medicamentos.
En conclusin: los conflictos de competencias o
demarcacin estricta e inamovible de lmites profe-
sionales deben reconocer como inters superior el
bienestar de los individuos a los que se presta el
servicio y amoldarse a la exigencia de cambio que
provocan las nuevas necesidades de atencin sanita-
ria en una poblacin que utiliza medicamentos en
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
of privacy and confidentiality as the rest of the health
care documentation.
With respect to the evaluation of available informa-
tion by the pharmacist: Having obtained the informa-
tion that results from data and that revealed by the
patient or his or her caregiver, the pharmacist evalua-
tion will always deal with the possible cause of a
determined way of medicines used; and the lack of
effectiveness, the appearance of toxicity, and the lack
or excess of indication of these medicines used.
With respect to the decision to inter vene in the
process of use of medicines by patient/users: Having
evaluated the information, the decision to intervene in
the use of medicines with the aim of improving health
results, has a counterweight to assume the responsible
professional part that responds to it.
Pharmaceutical Care has to this moment demons-
trated the diminishing of illness days in asthmatic
patients; reducing the number of hospitalizations, the
length of stay and suffering of relapses in patients with
cardiac impairments and coronar y illness; increasing
the compliance in the antibiotic treatment, including
anti-tuberculosis treatments; that is to say: intervening
in the use, it improves the medicines effectiveness.
In conclusion: The conflict of domain or strict immo-
vable demarcation of professional limits should recogni-
ze as superior interests the welfare of the individuals
to which the service is provided and mold themselves
to the demands of change which the new health care
necessities provoke in a population which uses medici-
nes in a greater quantity then ever, in an innovating
way and during an unlimited length of time.
Francisco Abal Ferrer
MD. General Practitioner in Carbayin Alto,
Siero (Asturias)
Flor lvarez de Toledo Saavedra
BSC. Pharm. Community Pharmacist in Oviedo