The call from my patient came late on a Saturday afternoon, the kind that begins with an apology and ends with a sigh.

“Doc,” he said, “I think there’s been a misunderstanding at the pharmacy.”

The pharmacist, he explained, had refused to fill the prescription—not because of allergies, drug interactions, shortages, or the usual insurance acrobatics, but because it was “outside the prescriber’s specialty.”

That phrase stopped me. It hung in the air like a legal clause nobody remembers approving.

I could have called the pharmacy. I often do. But phone calls flatten reality, and this already felt like a three‑dimensional problem—one unlikely to improve if compressed into hold-music and half‑heard explanations delivered by someone multitasking with a register. So I did what physicians occasionally do when the system behaves strangely and curiosity overwhelms reason: I got in my car and drove there.

I told myself it would be faster. A brief conversation. A quick clarification. Five minutes, tops.

This was my first mistake.

The prescription was for my patient with a neurogenic inflammatory dermatitis—one of several skin disorders driven by abnormal nerve‑immune signaling. I arrived at the diagnosis after performing a physical exam, taking a history, considering relevant laboratory studies, and applying the kind of clinical judgment typically acquired through medical school, residency, fellowship, and the slow accumulation of professional scar tissue.

I am a board‑certified dermatologist with subspecialty certification in dermatopathology. This means that skin, nerves, inflammation, and their overlapping misadventures occupy a large portion of my waking life. Occasionally my dreams as well.

The medication was a topical steroid cream. Conservative. Routine. The medical equivalent of toast.

At the pharmacy counter, the pharmacist frowned.

“I can’t fill this,” she said.

“Why not?” I asked, foolishly expecting an answer involving pharmacology, dosing, or—dare I hope—patient safety.

“It’s outside your specialty.”

Outside my specialty?

This was news to me, my residency program, my board‑certifying bodies, and the last two decades of my clinical practice.

I asked her to elaborate.

“Well,” she said, leaning in slightly and lowering her voice as though sharing classified material, “you’re a D.O.”

“Yes,” I said.

“And this medication treats a skin condition.”

“Yes.”

She nodded slowly, patiently, the way one does when explaining gravity to a confused houseplant.

“That’s not what you people do.”

At this point, I suspected the problem might be alphabetical.

“Are you confusing D.O. with O.D.?” I asked gently, the way one might explain basic physics to a golden retriever.

“No,” she bristled. “I know the difference.”

It turned out she did know the difference between a Doctor of Osteopathic Medicine and a Doctor of Optometry but still felt that my letters failed to grant me jurisdiction over dermal molecules. Apparently, the skin answers to a different governing body. Who—or what—I couldn’t determine without an inquisition.

By coincidence, I hadn’t arrived alone. My patient—confused, untreated, and clutching the original prescription like a boarding pass suddenly declared invalid—was still there. He had been asked to “step aside” while my credentials, scope, and possibly my moral fitness were being reviewed.

When he saw me approach the counter, his face brightened.

“Oh good,” he said. “Now you can explain it to her.”

At that point, the two of us stood shoulder to shoulder—two people who had independently done everything right, now united by the shared experience of being wrong anyway.

“I’m just doing my due diligence,” the pharmacist said.

Due diligence?

A phrase that now apparently includes determining whether a physician is sufficiently specialized to treat the organ systems they examine daily, using criteria known only to the pharmacy gods.

To be clear: pharmacists are essential. Knowledgeable. Overworked. Underappreciated. Medication safety depends on them.

But something peculiar has crept into modern health care: pharmacy‑based retrospective credentialing.

This is the process by which a physician evaluates a patient, makes a diagnosis, and writes a prescription—only for a pharmacist, who has never met the patient, examined them, or reviewed the chart, to decide whether the physician’s clinical judgment aligns with the pharmacist’s understanding of the physician’s résumé.

It’s like TSA, but for medicine. Shoes off. Judgment in the bin. Please step aside while we determine whether you’re allowed to touch your own patient.

In earlier times, if a pharmacist had concerns, they called the physician.

In the current era, the preferred workflow appears to be: refuse first, ask questions later, and notify the prescriber only if someone insists or shows up in person with a medical degree and a pulse.

My patient shifted his weight.

“So… what happens now?” he asked.

The answer, apparently, was relocation.

He traveled to another pharmacy across town, where the same prescription was filled in under five minutes. No debate. No alphabet analysis. No inquiry into whether nerves belong to skin or skin belongs to nerves.

Just care.

Which raises the uncomfortable question: who, exactly, is being protected by this system?

Not the patient, who lost time and continuity.

Not the physician, whose clinical judgment was nullified without examination or conversation.

Not even the pharmacist, already drowning in workload and liability without being drafted into an informal credentialing committee.

If pharmacists are now expected to decide which physicians may prescribe which medications, perhaps we should formalize the process.

Badges listing “Authorized Body Parts.”

A laminated chart at the counter titled Who Is Allowed to Treat What Today.

Perhaps a hotline: 1‑800‑CHECK‑THE‑LETTERS.

Or a smartphone app that scans diplomas and unlocks certain body parts like a medical version of parental controls.

Or—and I recognize this is a wildly radical proposal—we could return to the outdated idea that physicians diagnose and prescribe, pharmacists dispense and safeguard, and patients benefit from the collaboration rather than the confusion.

It’s a bold vision. Possibly unrealistic.

This wasn’t about safety.
It wasn’t about training.
It wasn’t about patient care.

It was about scope creep masquerading as vigilance—the quiet expansion of authority without the accompanying responsibility of diagnosis, longitudinal care, or accountability. It was about substituting professional boundaries with improvised judgment, exercised far from the exam room and untethered from the patient’s actual clinical story.

Until we confront that drift, patients will continue to stand at pharmacy counters caught between professions—one licensed to diagnose and treat, the other increasingly empowered to decide when that judgment no longer applies.

And when care is delayed or denied, it won’t be because medicine failed.

It will be because we allowed unchecked discretion to override clear roles, to the detriment of the very people the system exists to serve.

Author’s note: All characters and events are fictionalized. Any resemblance to real pharmacists, physicians, or bureaucratic absurdities is purely coincidental—and deeply concerning.

Arthur Lazarus, MD, MBA, is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine and the fictional series Real Medicine, Unreal Stories. His latest book, a novel, is Against the Tide: A Doctor’s Battle for an Undocumented Patient.