- Email: [email protected]
Addressing Common Problems
-~
Pharmacy: Profession in Transition By JEROME A. HALPERIN
tense as to whether the pharmacy curriculum should be extended to five years or remain a four-year program.
Warning Signals many ways, pharmacy today is a very different profession than it was 25-30 years ago. Yet, there are many similarities. The decade of the 1950s was exciting. The character of drugs was changing rapidly from substances obtained through processes of extraction and purification of active ingredients from plants, animals or microbes to new molecules developed through synthetic organic chemistry. Pharmacists were compounding 10% of the prescriptions they received-down from 80% in the 1920s. Jobs were plentiful, although the spectrum of choices was narrow. One could be a retail pharmacist or a hospital pharmacist. If pharmacists went into retail, they had a choice of being an entrepreneur or working for someone else, either an independent or a chain. The few (and they were few) who did not opt for retail or hospital pharmacy could continue on toward medicine or advanced degrees in chemistry or pharmacology. The profession did not provide the same opportunities to women as it does today. Intrusion by government into the practice was almost nonexistent. Other than the State Board exam for registration and rare visits to pharmacies by State Board inspectors, state governments did not affect the practice of the profession the federal government had little to say about pharmacy. In the late 1950s, debate was in-
Jerome A. Halperin is deputy director of the Bureau of Drugs, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857. This article is adapted from his speech presented at the Rutgers University College of Pharmacy commencement, May 21, 1981. _ _6~
What has happened to pharmacy over these past few decades and why do we hear warning signals all around us? Has pharmacy become a profession . in trouble or are these the signals of a profession in transition? In his thought-provoking article, "Introspection and Challenge: Anticipating Pharmacy's Future" (American Pharmacy February 1981, p. 30), APhA President William Apple wrote: In taking pharmacy's pulse, the first thing one must note is that the esprit de corps of the profession is on the wane .. .. I have never felt that pharmacy's spirit was at a lower ebb. Apple reported that pharmacy manpower statistics project a 14% unemployment rate nationwide for pharmacists in 10 years. He accused the profession of divided, disorganized and shortsighted leadership, factionalism, elitism, and self-interest. He said that pharmacists have failed to understand and address appropriately the challenges that face the profession. He warned that the profession does not have the kind of analytic and planning expertise it needs to solve these problems. Apple characterized pharmacy's foundation as weak, suggesting that the single most significant weakness is the proliferation. of pharmacy organizations whose divergence has prevented effective dealings with government regarding programs and policies that have caused economic hardships for pharmacy. Finally, Apple said that pharmacists are suffering from a lack of public recognition and that they can no longer remain ... imprisoned within their dispensing cubicles where they have abandoned--or have been forced to
abandon-their patients. They har left important pat~ent needs-th needs for human contact and caring to others. Too often, pharmacists hat failed or refused to communicate bot/ their concern and their pharmaceu tical competence to their patients. Apple's voice is not alone. Th April 3, 1981, issue of Drug Topic reported a study from the Univer sity of Utah under the headline "Low Motivation, Poor Self-estee Mark Pharmacy." 1 1
Attending to Problems In a recent article, "Continuit and Change: Thinking in New Way· about Large and Persistent Pro Iems,'' David J. Rose, a professor o nuclear physics at MIT, wrote thi interesting bit of philosophy: Everything so far has supported th thesis that societies-whole civiliza tions-get into trouble by not payinl attention to their problems. Or, they do pay attention, they do so care lessly, even perversely. 2 Rose was speaking on a macr scale, but the same observation may be pertinent to ·a micro systefJ -or a profession. Judging from the remarks o health care economist Eli Ginzber at the 1981 APhA annual meeting, ! appears that Rose may be corre (see p. 22). Ginzberg believes tha colleges of pharmacy admitted to many students in the early 1970 and that the graduates will not all b absorbed into the labor force fo some time to come. This problem-, he feels, will be ex acerbated by the projected 40% i crease in the number of physician by 1990. As the physician supply in creases, physician income will d crease, making it unlikely that ph) sicians will yield any turf to pha macists or other health care pracb tioners. The debate about educational r quirements has shifted up on notch from the late 1950s. Now th question is whether pharmac should require a six-year curriculu with the doctoral degree as the sin 1
American Pharmac'i_VoL NS21 No. 8.
1
I
1
I
gle entry requirement into the profession or whether the current system of the five-year bachelor and six-year doctorate degrees should remain. An important, but inadequately addressed question is, "How much education is needed for what?" Pharmacy is changing and the educational requirements must evolve with these changes. If it appears that we pharmacists are helpless victims of change, let me remind you of Shakespeare's often quoted sentiment, "The fault, dear Brutus, is not in our stars but in ourselves." I do not share the pessimism of Apple or Ginzberg or others who, like Og, the leprechaun in "Finian' s Rainbow," go about proclaiming, "Gloom and doom!" True, pharmacy may be having some troubles now. But the question is whether
the troubles are symptoms of serious underlying disease or merely of growing pains. Rose spoke of professions as biological organisms. He wrote, Professional disciplines are like people: they are born; occasionally they die. They form societies to assist i1z their nourishment. They show a strong sense of self-awareness by drawing logical peripheries and declaring that what exists inside their "field" is part of the discipline and what is outside belongs elsewhere. ... Disciplines grow up and have children, called subdisciplines, which also later become disciplines . ...
The Specialty Niche Pharmacy is such a discipline. It is now at the point of producing subdisciplines that are seeking to find their proper niches in the health care system.
I am encouraged and excited by the trend toward specialization. While a new subdiscipline has to fight for a toehold, if it can carve out that unique niche in the system or society which spawned it, ultimately it will be successful. As scientific, technological and informational requirements of drugs expand, niches for new and unique pharmaceutical services will appear. Nuclear pharmacy, which had its beginnings only about two decades ago, is the most successful subdiscipline to date. It is the first specialty recognized by the Board of Pharmaceutical Specialties and is about to hold the first examination to accredit practitioners. Clinical pharmacy, as a subdiscipline, is faring less well. It has not yet found its niche; it has not been accepted by physicians. Ginzberg says there will be relatively few po-
Advice to Graduating Pharmacists A s you embark on your careers in pharmacy, a profession at the threshold of significant change, what should you expect from it and what should it expect from you? It's a two-way street; Francis Bacon recognized that almost 400 years ago when he said: I hold every ·man a debtor to his profession ... as men seek to receive countenance and profit [from it], so ought they, of duty, endeavor to be a help and ornament thereto.
to see opportunities for pharmacists in the 1980s that didn't exist in the recent past. I believe the overemployment projections for the 1990s are wrong; they do not consider the new and nontraditional roles pharmacists can and will fill in health care. • Finally; you should expect the satisfaction that your endeavors have contributed to the health and well-being of society.
Y ou have a right to expect: • A challenge to measure up to the demands of its science, to keep abreast of the knowledge explosion about drugs so that you can provide your patients and your professional colleagues with the information they need to optimize the safety and effectiveness of the use of the drugs in our pharmacological armamentarium. Remember, the focus of pharmacy today is on service, and the service is the act of providing information, not just a product. • An opportunity to advance the science and the practice of pharmacy by expanding its peripheries into new areas of science, health administration, health planning, medicine, law, and management. But for pharmacists to realize this opportunity will require additional education and, perhaps, new credentials. Today's pharmacy education is a precious commodity. It is a foundation of science on which additional education can build a profession with unique training to fill these emerging niches in the health care system. One need only read the current pharmacy literature
A
llerican Pharmacy Vol. NS21, No. 8, August 1981/447
nd what should our profession expect from you? • First, commitment-a degree in pharmacy and a professional license are not guarantees of a scientific or a professional career. Your personal inclination and motivation to achieve are necessary. To grow in your profession you must practice itpractice in its real sense. Professional practice involves continued study, mental development and maximum use of knowledge, not just mindless repetition of manipulative skills. • Second, contribution of your intellectual resources and energies to improve the profession by expanding its frontiers into new areas of health services, and by fortifying and strengthening its existing domain to make pharmacy a more integral and vital partner in health care. • And finally, pharmacy should expect the dedication of your lives to the honor and integrity of your profession and to improving and maintaining the health of your fellow humans. -Jerome A. Halperin
7
sitions for clinical pharmacists through 1990, and Apple is even more pessimistic about their future. In a period of oversupply of physicians, clinical pharmacy appears to compete with them. Therefore, carving out a niche will be difficult. Where it can coexist with medicine, clinical pharmacy will succeed. Where it will conflict with medicine, it will fail. When the health care delivery system includes ways to pay for the clinical pharmacist's services, the place for these services will be assured. The Food and Drug Administration currently is experimenting with the employment of clinical pharmacists in drug evaluation. It is a little early to judge the results, but I believe the chances for success are good. Pediatric and geriatric pharmacy and psychopharmacy are sub-subdisciplines . Their viability depends on the success of clinical pharmacy, their parent. Consultant pharmacy and drug information are specialties which, w hile not yet as successful as nuclear pharmacy, appear to be finding their particular niches. Again, FDA has found it useful to have pharmacists with drug information training and experience involved in drug labeling, drug utilization, poison control, and adverse drug reaction monitoring programs . With advanced training in epidemiology, several pharmacists have become key members of our drug epidemiology program. I predict that, as postmarketing surveillance of new drugs expands, pharmacists with training in drug information and epidemiology will find exciting and rewarding opportunities in industry, government and academia.
New Drugs, New Roles The environment of the practice of pharmacy also is in transition. Vve are at the threshold of a new generation of drugs. We see before us exciting new horizons: drugs, including hormones, enzymes and other complex polypeptides are being mass produced by bacterial factories for diseases heretofore not treatable. The age of recombinant DNA has
8
arrived. Already recombinant DNAproduced human insulin, human growth hormone (and its analogs), thymosin, ACTH, endorphins, interferons, vaccines, human serum albumin, and urokinase are either in clinical trials or soon will be. Our quest for Ehrlich's magic bullet continues, but we are getting closer. We are seeing new delivery systems, including implants which release drugs in local areas over long periods of time, transdermal absorption, and drugs attached to circulating liposomes. What do these new drugs and delivery systems mean for pharmacy? How will these complex new drugs be formulated, packaged and labeled? How will they be dispensed? Will other patient populations have needs for special pharmaceutical services which will develop as science and technology expand and these new drugs are approved for marketing? It is inevitable that answers to these questions will emerge and that innovative services and roles for pharmacists will result. The development of new drugs and nontraditional systems of their delivery to human beings on an individually tailored basis will give pharmacists a whole new role . These new demands will force changes in education, in the environment of practice, and in the interaction of pharmacists with their patients and other professionals. The mainstream practices of pharmacy are changing rapidly. Retail pharmacy is shifting from p rivate ownership-where the pharmacist/employer was in command-to chain ownership where the pharmacist/employee is more common. Pharmacists will need new skills in management, employee relations and finance to deal with this transition. The family-owned pharmacy, or "one-man" store, is rapidly becoming a thing of the past. These changes in the character and the locus of the practice of pharmacy are not unique to U.S. pharmacy either. In Japan, where retail pharmacy has traditionally not been the major vector for dispensing prescription drugs to patients, even fewer pharmacy graduates are
choosing careers in retail pharmacy Statistics for 1980 show that onh 10% are now going into retail pha;. macy while 19o/o are continuing thei1 education in graduate school anc 22% are accepting positions in the pharmaceutical industry. The over· supply problem is already being felt 15% of the graduates had not foun positions at the time of the survey.
Patient Counseling is Key Today fewer than 1% of prescrip tions require compounding by a pharmacist. Compounding is be· coming a lost art . Instead of com pounding, pharmacists musl emerge from the prescription de· partments to speak with-indeed to counsel-their patients on the prop· er way to take these new drugs t maximize their effectiveness andre· duce their potential for adverse ef· fects . The basic product of the pharma· cist' s labor today is knowledge, no the medicine. The profession right· fully continues to urge that pharma· cists disseminate this knowledge t their patients. It is on this point-providing in· formation to patients-that FDA can claim credit for giving pharmacy a flag to rally around. The patienl package insert (PPI) regulation tha would require pharmacists to dis· pense a PPI with each new prescri~ tion for 10 different drugs was like 1 shot of adrenalin for the profession Not since Teddy Roosevelt led a SanJuan has Washington witnesse such a spirited charge up a hill. Ev· ery pharmacy organization has vig· orously lobbied the Congress, anc has written and spoken against thi! regulation to officials in the admin: istration from the President anc OMB Director to the Commissioner of Food and Drugs. Despite its unpopularity, the PP regulation deserves credit for ac· complishing two things: it madf pharmacists more sensitive to th need for and importance of provid ing information to patients aboU the drugs they take, and it has give pharmacy a common cause o which to unite. If pharmacy has sui fered from a proliferation of orga nizations with divergent and ofte competing goals, it is seeing har
American Pharmacy Vol. NS21 , No.8, August 198
mony on this point. It's nice to see the interest, enthusiasm and passion in the arguments; it's too bad it had to be on this issue. -
Future Opportunities Pharmacy is a profession in transition. As different as it is in the 1980s from pharmacy in the 1950s, so will pharmacy differ 30 years in the future from the way it is today. No longer will the pharmacist be thought of only as the person behind the counter who fills the prescription. Pharmacists will be recognized and valued as broadly trained professionals who practice in all aspects of the health care system involving the invention, development, production, evaluation, and use of drugs, devices and other health services and products. The opportunities are diverse and numer'ous. If the profession is to continue to grow and to flourish through this transition, we must be committed to improving the value and quality of its principal asset-its peoplethrough further education, development and motivation. It is gratifying to be a part of a profession that still has great potential for development. At the same time, it is sobering to realize that at. tainment of much of that potential f depends on the attitudes and per1 formance of its members-individ1 ually and collectively. 1 If we define the many po~sible roles for our profession and then ex,. pand the education and training l' necessary to fill those roles, we will .' be contributing mightily to the pro~~ fession's continued vitality. l And if each of us practicing indiIL v.idually demonstrates that pharmaer Cists are trained, dedicated and .competent members of the health PI care team, we will be recognized by c· our professional colleagues and the )!public as integral and indispenhf sible. o
1
d iU References ef ~· Drug Topics, 125, 36 (1981) . Of . D.}. Rose, Technology Review, 83, 52 (1981).
Jl' ~a
en
ar
Addressing Common Problems Patients in Saskatchewan, Canada, had drug information and education brought straight into their living rooms last year through an audivisual program "Drug Information -A Consumer's Right," developed by the University of Saskatchewan Hospital and College of Pharmacy and broadcast by local television stations. The 30-minute program, conceived and written by Pharmacist Deborah Matthews* while she was a pharmacy resident at the hospital, was designed to promote the rational use of drugs by showing patients that they need drug information and have a right to obtain it. The program also made health care practictioners more aware of their patients' drug information needs. The idea for the program was based partly on a finding that "consumers are unaware of what services the modern community pharmacist performs but react positively to a program of comprehensive services when they are informed of its features. " 1 Matthews believes that it is "an injustice to expect a patient to understand the importance and appropriate use of ... drugs if the information is not provided. To ensure the rational use of drugs, all health care practitioners should be made aware of the drug information needs of the consumer.'' •Matthews is currently a staff pharmacist at Children's Hospital, Calgary, Alberta .
The program, which cost about $3,500 (Canadian) to produce, took the form of a panel discussion between a host and a pharmacy resident, a physician and a pharmacist. The practitioners answered and discussed questions posed by the pharmacy resident concerning situations presented in three prefilmed vignettes. Besides being televised in Saskatoon and neighboring towns, the program has been presented to consumer groups, pharmacy undergraduate students, staffs at a number of hospitals and colleges, and pharmacists participating in continuing education sessions. Although no formal evaluation of the program has been attempted, responses from consumers and health professionals indicate that it has been well-received and valuable. After seeing the program, several consumer groups and hospitals, a pharmacy school, and a community pharmacist requested copies of the program for their own use. The Saskatchewan Pharmaceutical Association now has printed a poster listing the eight consumer medication "rights" and is promoting it for display in outpatient and community pharmacies. -PAM
Reference 1. "Communicating the Value of Comprehensive Pharmaceutical Services to the Consumer, " Report of the Dichter Ins titute for Motivational Resea rch , American Pharmaceutical Association, Wa s hington , DC, 1973 .
Consumer Rights As a guide for patients to obtain the proper information, eight consumer "rights" were outlined on the program. Patients were encouraged to ask their pharmacists: • The name and strength of any medication they take; • The purpose of the medication; • When and how the medication is to be taken; • How long the medication should be taken; • What side effects may occur and how they should be handled if they do occur; • What side effects should be reported to a physician; • What food, alcohol, prescribed and nonprescribed drugs should be avoided; • How the medication should be stored.
9
Pharmacy: Profession in Transition By JEROME A. HALPERIN
tense as to whether the pharmacy curriculum should be extended to five years or remain a four-year program.
Warning Signals many ways, pharmacy today is a very different profession than it was 25-30 years ago. Yet, there are many similarities. The decade of the 1950s was exciting. The character of drugs was changing rapidly from substances obtained through processes of extraction and purification of active ingredients from plants, animals or microbes to new molecules developed through synthetic organic chemistry. Pharmacists were compounding 10% of the prescriptions they received-down from 80% in the 1920s. Jobs were plentiful, although the spectrum of choices was narrow. One could be a retail pharmacist or a hospital pharmacist. If pharmacists went into retail, they had a choice of being an entrepreneur or working for someone else, either an independent or a chain. The few (and they were few) who did not opt for retail or hospital pharmacy could continue on toward medicine or advanced degrees in chemistry or pharmacology. The profession did not provide the same opportunities to women as it does today. Intrusion by government into the practice was almost nonexistent. Other than the State Board exam for registration and rare visits to pharmacies by State Board inspectors, state governments did not affect the practice of the profession the federal government had little to say about pharmacy. In the late 1950s, debate was in-
Jerome A. Halperin is deputy director of the Bureau of Drugs, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857. This article is adapted from his speech presented at the Rutgers University College of Pharmacy commencement, May 21, 1981. _ _6~
What has happened to pharmacy over these past few decades and why do we hear warning signals all around us? Has pharmacy become a profession . in trouble or are these the signals of a profession in transition? In his thought-provoking article, "Introspection and Challenge: Anticipating Pharmacy's Future" (American Pharmacy February 1981, p. 30), APhA President William Apple wrote: In taking pharmacy's pulse, the first thing one must note is that the esprit de corps of the profession is on the wane .. .. I have never felt that pharmacy's spirit was at a lower ebb. Apple reported that pharmacy manpower statistics project a 14% unemployment rate nationwide for pharmacists in 10 years. He accused the profession of divided, disorganized and shortsighted leadership, factionalism, elitism, and self-interest. He said that pharmacists have failed to understand and address appropriately the challenges that face the profession. He warned that the profession does not have the kind of analytic and planning expertise it needs to solve these problems. Apple characterized pharmacy's foundation as weak, suggesting that the single most significant weakness is the proliferation. of pharmacy organizations whose divergence has prevented effective dealings with government regarding programs and policies that have caused economic hardships for pharmacy. Finally, Apple said that pharmacists are suffering from a lack of public recognition and that they can no longer remain ... imprisoned within their dispensing cubicles where they have abandoned--or have been forced to
abandon-their patients. They har left important pat~ent needs-th needs for human contact and caring to others. Too often, pharmacists hat failed or refused to communicate bot/ their concern and their pharmaceu tical competence to their patients. Apple's voice is not alone. Th April 3, 1981, issue of Drug Topic reported a study from the Univer sity of Utah under the headline "Low Motivation, Poor Self-estee Mark Pharmacy." 1 1
Attending to Problems In a recent article, "Continuit and Change: Thinking in New Way· about Large and Persistent Pro Iems,'' David J. Rose, a professor o nuclear physics at MIT, wrote thi interesting bit of philosophy: Everything so far has supported th thesis that societies-whole civiliza tions-get into trouble by not payinl attention to their problems. Or, they do pay attention, they do so care lessly, even perversely. 2 Rose was speaking on a macr scale, but the same observation may be pertinent to ·a micro systefJ -or a profession. Judging from the remarks o health care economist Eli Ginzber at the 1981 APhA annual meeting, ! appears that Rose may be corre (see p. 22). Ginzberg believes tha colleges of pharmacy admitted to many students in the early 1970 and that the graduates will not all b absorbed into the labor force fo some time to come. This problem-, he feels, will be ex acerbated by the projected 40% i crease in the number of physician by 1990. As the physician supply in creases, physician income will d crease, making it unlikely that ph) sicians will yield any turf to pha macists or other health care pracb tioners. The debate about educational r quirements has shifted up on notch from the late 1950s. Now th question is whether pharmac should require a six-year curriculu with the doctoral degree as the sin 1
American Pharmac'i_VoL NS21 No. 8.
1
I
1
I
gle entry requirement into the profession or whether the current system of the five-year bachelor and six-year doctorate degrees should remain. An important, but inadequately addressed question is, "How much education is needed for what?" Pharmacy is changing and the educational requirements must evolve with these changes. If it appears that we pharmacists are helpless victims of change, let me remind you of Shakespeare's often quoted sentiment, "The fault, dear Brutus, is not in our stars but in ourselves." I do not share the pessimism of Apple or Ginzberg or others who, like Og, the leprechaun in "Finian' s Rainbow," go about proclaiming, "Gloom and doom!" True, pharmacy may be having some troubles now. But the question is whether
the troubles are symptoms of serious underlying disease or merely of growing pains. Rose spoke of professions as biological organisms. He wrote, Professional disciplines are like people: they are born; occasionally they die. They form societies to assist i1z their nourishment. They show a strong sense of self-awareness by drawing logical peripheries and declaring that what exists inside their "field" is part of the discipline and what is outside belongs elsewhere. ... Disciplines grow up and have children, called subdisciplines, which also later become disciplines . ...
The Specialty Niche Pharmacy is such a discipline. It is now at the point of producing subdisciplines that are seeking to find their proper niches in the health care system.
I am encouraged and excited by the trend toward specialization. While a new subdiscipline has to fight for a toehold, if it can carve out that unique niche in the system or society which spawned it, ultimately it will be successful. As scientific, technological and informational requirements of drugs expand, niches for new and unique pharmaceutical services will appear. Nuclear pharmacy, which had its beginnings only about two decades ago, is the most successful subdiscipline to date. It is the first specialty recognized by the Board of Pharmaceutical Specialties and is about to hold the first examination to accredit practitioners. Clinical pharmacy, as a subdiscipline, is faring less well. It has not yet found its niche; it has not been accepted by physicians. Ginzberg says there will be relatively few po-
Advice to Graduating Pharmacists A s you embark on your careers in pharmacy, a profession at the threshold of significant change, what should you expect from it and what should it expect from you? It's a two-way street; Francis Bacon recognized that almost 400 years ago when he said: I hold every ·man a debtor to his profession ... as men seek to receive countenance and profit [from it], so ought they, of duty, endeavor to be a help and ornament thereto.
to see opportunities for pharmacists in the 1980s that didn't exist in the recent past. I believe the overemployment projections for the 1990s are wrong; they do not consider the new and nontraditional roles pharmacists can and will fill in health care. • Finally; you should expect the satisfaction that your endeavors have contributed to the health and well-being of society.
Y ou have a right to expect: • A challenge to measure up to the demands of its science, to keep abreast of the knowledge explosion about drugs so that you can provide your patients and your professional colleagues with the information they need to optimize the safety and effectiveness of the use of the drugs in our pharmacological armamentarium. Remember, the focus of pharmacy today is on service, and the service is the act of providing information, not just a product. • An opportunity to advance the science and the practice of pharmacy by expanding its peripheries into new areas of science, health administration, health planning, medicine, law, and management. But for pharmacists to realize this opportunity will require additional education and, perhaps, new credentials. Today's pharmacy education is a precious commodity. It is a foundation of science on which additional education can build a profession with unique training to fill these emerging niches in the health care system. One need only read the current pharmacy literature
A
llerican Pharmacy Vol. NS21, No. 8, August 1981/447
nd what should our profession expect from you? • First, commitment-a degree in pharmacy and a professional license are not guarantees of a scientific or a professional career. Your personal inclination and motivation to achieve are necessary. To grow in your profession you must practice itpractice in its real sense. Professional practice involves continued study, mental development and maximum use of knowledge, not just mindless repetition of manipulative skills. • Second, contribution of your intellectual resources and energies to improve the profession by expanding its frontiers into new areas of health services, and by fortifying and strengthening its existing domain to make pharmacy a more integral and vital partner in health care. • And finally, pharmacy should expect the dedication of your lives to the honor and integrity of your profession and to improving and maintaining the health of your fellow humans. -Jerome A. Halperin
7
sitions for clinical pharmacists through 1990, and Apple is even more pessimistic about their future. In a period of oversupply of physicians, clinical pharmacy appears to compete with them. Therefore, carving out a niche will be difficult. Where it can coexist with medicine, clinical pharmacy will succeed. Where it will conflict with medicine, it will fail. When the health care delivery system includes ways to pay for the clinical pharmacist's services, the place for these services will be assured. The Food and Drug Administration currently is experimenting with the employment of clinical pharmacists in drug evaluation. It is a little early to judge the results, but I believe the chances for success are good. Pediatric and geriatric pharmacy and psychopharmacy are sub-subdisciplines . Their viability depends on the success of clinical pharmacy, their parent. Consultant pharmacy and drug information are specialties which, w hile not yet as successful as nuclear pharmacy, appear to be finding their particular niches. Again, FDA has found it useful to have pharmacists with drug information training and experience involved in drug labeling, drug utilization, poison control, and adverse drug reaction monitoring programs . With advanced training in epidemiology, several pharmacists have become key members of our drug epidemiology program. I predict that, as postmarketing surveillance of new drugs expands, pharmacists with training in drug information and epidemiology will find exciting and rewarding opportunities in industry, government and academia.
New Drugs, New Roles The environment of the practice of pharmacy also is in transition. Vve are at the threshold of a new generation of drugs. We see before us exciting new horizons: drugs, including hormones, enzymes and other complex polypeptides are being mass produced by bacterial factories for diseases heretofore not treatable. The age of recombinant DNA has
8
arrived. Already recombinant DNAproduced human insulin, human growth hormone (and its analogs), thymosin, ACTH, endorphins, interferons, vaccines, human serum albumin, and urokinase are either in clinical trials or soon will be. Our quest for Ehrlich's magic bullet continues, but we are getting closer. We are seeing new delivery systems, including implants which release drugs in local areas over long periods of time, transdermal absorption, and drugs attached to circulating liposomes. What do these new drugs and delivery systems mean for pharmacy? How will these complex new drugs be formulated, packaged and labeled? How will they be dispensed? Will other patient populations have needs for special pharmaceutical services which will develop as science and technology expand and these new drugs are approved for marketing? It is inevitable that answers to these questions will emerge and that innovative services and roles for pharmacists will result. The development of new drugs and nontraditional systems of their delivery to human beings on an individually tailored basis will give pharmacists a whole new role . These new demands will force changes in education, in the environment of practice, and in the interaction of pharmacists with their patients and other professionals. The mainstream practices of pharmacy are changing rapidly. Retail pharmacy is shifting from p rivate ownership-where the pharmacist/employer was in command-to chain ownership where the pharmacist/employee is more common. Pharmacists will need new skills in management, employee relations and finance to deal with this transition. The family-owned pharmacy, or "one-man" store, is rapidly becoming a thing of the past. These changes in the character and the locus of the practice of pharmacy are not unique to U.S. pharmacy either. In Japan, where retail pharmacy has traditionally not been the major vector for dispensing prescription drugs to patients, even fewer pharmacy graduates are
choosing careers in retail pharmacy Statistics for 1980 show that onh 10% are now going into retail pha;. macy while 19o/o are continuing thei1 education in graduate school anc 22% are accepting positions in the pharmaceutical industry. The over· supply problem is already being felt 15% of the graduates had not foun positions at the time of the survey.
Patient Counseling is Key Today fewer than 1% of prescrip tions require compounding by a pharmacist. Compounding is be· coming a lost art . Instead of com pounding, pharmacists musl emerge from the prescription de· partments to speak with-indeed to counsel-their patients on the prop· er way to take these new drugs t maximize their effectiveness andre· duce their potential for adverse ef· fects . The basic product of the pharma· cist' s labor today is knowledge, no the medicine. The profession right· fully continues to urge that pharma· cists disseminate this knowledge t their patients. It is on this point-providing in· formation to patients-that FDA can claim credit for giving pharmacy a flag to rally around. The patienl package insert (PPI) regulation tha would require pharmacists to dis· pense a PPI with each new prescri~ tion for 10 different drugs was like 1 shot of adrenalin for the profession Not since Teddy Roosevelt led a SanJuan has Washington witnesse such a spirited charge up a hill. Ev· ery pharmacy organization has vig· orously lobbied the Congress, anc has written and spoken against thi! regulation to officials in the admin: istration from the President anc OMB Director to the Commissioner of Food and Drugs. Despite its unpopularity, the PP regulation deserves credit for ac· complishing two things: it madf pharmacists more sensitive to th need for and importance of provid ing information to patients aboU the drugs they take, and it has give pharmacy a common cause o which to unite. If pharmacy has sui fered from a proliferation of orga nizations with divergent and ofte competing goals, it is seeing har
American Pharmacy Vol. NS21 , No.8, August 198
mony on this point. It's nice to see the interest, enthusiasm and passion in the arguments; it's too bad it had to be on this issue. -
Future Opportunities Pharmacy is a profession in transition. As different as it is in the 1980s from pharmacy in the 1950s, so will pharmacy differ 30 years in the future from the way it is today. No longer will the pharmacist be thought of only as the person behind the counter who fills the prescription. Pharmacists will be recognized and valued as broadly trained professionals who practice in all aspects of the health care system involving the invention, development, production, evaluation, and use of drugs, devices and other health services and products. The opportunities are diverse and numer'ous. If the profession is to continue to grow and to flourish through this transition, we must be committed to improving the value and quality of its principal asset-its peoplethrough further education, development and motivation. It is gratifying to be a part of a profession that still has great potential for development. At the same time, it is sobering to realize that at. tainment of much of that potential f depends on the attitudes and per1 formance of its members-individ1 ually and collectively. 1 If we define the many po~sible roles for our profession and then ex,. pand the education and training l' necessary to fill those roles, we will .' be contributing mightily to the pro~~ fession's continued vitality. l And if each of us practicing indiIL v.idually demonstrates that pharmaer Cists are trained, dedicated and .competent members of the health PI care team, we will be recognized by c· our professional colleagues and the )!public as integral and indispenhf sible. o
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d iU References ef ~· Drug Topics, 125, 36 (1981) . Of . D.}. Rose, Technology Review, 83, 52 (1981).
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Addressing Common Problems Patients in Saskatchewan, Canada, had drug information and education brought straight into their living rooms last year through an audivisual program "Drug Information -A Consumer's Right," developed by the University of Saskatchewan Hospital and College of Pharmacy and broadcast by local television stations. The 30-minute program, conceived and written by Pharmacist Deborah Matthews* while she was a pharmacy resident at the hospital, was designed to promote the rational use of drugs by showing patients that they need drug information and have a right to obtain it. The program also made health care practictioners more aware of their patients' drug information needs. The idea for the program was based partly on a finding that "consumers are unaware of what services the modern community pharmacist performs but react positively to a program of comprehensive services when they are informed of its features. " 1 Matthews believes that it is "an injustice to expect a patient to understand the importance and appropriate use of ... drugs if the information is not provided. To ensure the rational use of drugs, all health care practitioners should be made aware of the drug information needs of the consumer.'' •Matthews is currently a staff pharmacist at Children's Hospital, Calgary, Alberta .
The program, which cost about $3,500 (Canadian) to produce, took the form of a panel discussion between a host and a pharmacy resident, a physician and a pharmacist. The practitioners answered and discussed questions posed by the pharmacy resident concerning situations presented in three prefilmed vignettes. Besides being televised in Saskatoon and neighboring towns, the program has been presented to consumer groups, pharmacy undergraduate students, staffs at a number of hospitals and colleges, and pharmacists participating in continuing education sessions. Although no formal evaluation of the program has been attempted, responses from consumers and health professionals indicate that it has been well-received and valuable. After seeing the program, several consumer groups and hospitals, a pharmacy school, and a community pharmacist requested copies of the program for their own use. The Saskatchewan Pharmaceutical Association now has printed a poster listing the eight consumer medication "rights" and is promoting it for display in outpatient and community pharmacies. -PAM
Reference 1. "Communicating the Value of Comprehensive Pharmaceutical Services to the Consumer, " Report of the Dichter Ins titute for Motivational Resea rch , American Pharmaceutical Association, Wa s hington , DC, 1973 .
Consumer Rights As a guide for patients to obtain the proper information, eight consumer "rights" were outlined on the program. Patients were encouraged to ask their pharmacists: • The name and strength of any medication they take; • The purpose of the medication; • When and how the medication is to be taken; • How long the medication should be taken; • What side effects may occur and how they should be handled if they do occur; • What side effects should be reported to a physician; • What food, alcohol, prescribed and nonprescribed drugs should be avoided; • How the medication should be stored.
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