Another key difference between hospital and community pharmacists’ interactions with the patient body is the status of the hospital pharmacy gaze as one of many practitioner gazes which the patient body is subject to given the number of practitioners who become involved in the patient’s care. Here, then, the pharmacy gaze which constructs the patient as a medications-user is one of a number of perspectives through which the ill body is narrated by the bioclinical collective. Unlike in community settings, where practice co-location and collaboration are much more limited, these varying gazes are not deployed in isolation but instead, as May (1992) suggests, work interactionally to construct a narrative of the patient body which is aligned with hospital expertise, knowledge and policy.
As an example of such divergent gazes at work in the hospital setting, May highlights the particular way in which nurses utilise the structure of their practice (i.e. being based on wards and having more time to speak with patients) and position within the hospital division of labour to cultivate both a foreground and background knowledge of patients. Hence, nurses gaze at patients both as a particular, clinically- defined set of care requirements (foreground knowledge obtained through a clinical
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gaze which seeks ‘truths’ about the patient body) and as idiosyncratic and private subjects (background knowledge obtained through a more nursing-specific gaze).
The exploration of different gazes in the hospital setting is useful in understanding the different ways in which patients are constructed by different health care professionals and for placing the pharmacy gaze within wider understandings of patients. Much of the work in this area, however, treats different clinical gazes or ways of knowing patients as discrete and related solely to that particular field of practice. The data, however, show that through bioclinical collective practices, pharmacists engage with and negotiate ‘gazes’ other than that of their own profession, particularly around the time of discharge.
This multi-gaze that the patient body is subject to in hospital settings is facilitated through hospital policy generally allowing all health care professionals that interact with patients to have access to patient medical records. Berg and Bowker (1997) have analysed patient medical records from a Foucauldian perspective and argue that patient medical records produce a history, geography and memory of the patient through verified (i.e. tested) ‘truths’ about the patient body. Moreover, they argue that patient medical records are fundamental to the everyday production of the patient body and to the production of the organisations that enact and treat it. Hence, the relations in the hospital (between actors in the bioclinical collective and between patients and practitioners) are mediated through the medical record.
The data here confirm this general argument that access to patient medical records is of central importance to hospital and community pharmacy practice. In hospitals, allowing multiple and diverse practice populations to access, and contribute to, patient medical records collates multiple practitioner gazes in one documentary space. This documentary space serves to construct a history, geography and memory of a multi-faceted patient body through the mobilisation of various fields of expertise, as Hospital Pharmacist 6 shows;
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“So it’s not just pharmacy but OTs and physios and all sorts of people who have access... all write in the patient’s notes” (HP 6- Director of Pharmacy)
In the community setting, the boundaries of expertise that are drawn around GPs create an intellectual and practice hierarchy between GPs and pharmacists which is manifested in the restriction of medical record access to the GP and, potentially, staff working in the GP surgery. As such, pharmacists practising in community settings are not granted the power to see patient records, or enter onto them observations based on pharmacy expertise. As such, the record is an important ‘inscription device’ that acts to confirm diagnostic power and expertise. This limitation of the gazes through which community pharmacists see patients was understood by respondents as being restrictive for practice as the complexities of the ill body, and their potential impact on the pharmacological action of therapies, could not be effectively managed by the community pharmacist in the same way as in hospitals, as Community Pharmacist 8 demonstrates;
“How community pharmacists are supposed to make sure that the patient is moving on with the correct medication- it’s virtually impossible without records” (CP8)
In their analysis of EPS, Petrakaki et al. (2012) unsurprisingly argue that increased pharmacist access to patient medical records would enhance community pharmacy’s status in terms of increased capacity for decision-making; expanding their professional jurisdictions; engaging them in clinical judgements through an increased information pool; strengthening inter-professional trust; and rendering them part of the ‘NHS family’. Moreover, as the quote above highlights, resetting the boundaries of medical record access may also be beneficial for patients through improved counselling practices and adherence. This extension of access to patient medical records, however, presents a number of practical and ethical challenges. Hobson et al. (2010) note, for example, that patients are reluctant for pharmacists to access sensitive, and what is largely perceived to be irrelevant, medical information such as sexual health issues. This perspective is reflected in an earlier Patients’
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Association (2008) report where the practical issues of limiting medical record access to pharmacists alone (rather than all staff working in pharmacies) was also centralised. Additionally, extending medical record access undermines a central feature of the medical technocracy that exists in primary care practice. Hence, the potential for community pharmacists to interact with patient bodies through a biomedical gaze is primarily limited by the restrictions placed on medical record access in routine primary care practice. However, the increasingly clinical future of pharmacy (detailed below) means that such debates around record access will become more common.