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A Challenge to American Pharmacy
or many pharmacists the annual meeting of APHA represents a special opportunity to examine the profession they serve, to consider the opportunities and problems facing pharmacy today and to help chart the course of pharmacy education, pharmacy research and especially pharmacy service so that their profession can make its maximum contribution to the American people. As I grow older-and, I hope, wiserI find that about the only lasting satisfactions are associated with what one gives to others-to family, to friends, to the community at large. The pharmacist is among the most fortunate of men in that his daily work can bring him routinely a good measure of life's satisfactions. I have one admonition to the pharmacist in this matter, however. His obligations for public service are not limited to the patients who enter his pharmacy; they extend to the community in which he works. For some that community is a village; for others it is a whole state; for still others, a nation.
F
a challenge
to
• american pharmacy'
by Henry T. Clark, Jr., MD
increasing demand for services Up until very recently, there was really no body of public opinion on health matters. There was simply the hope in the heart of every man that his needs would be met at the time of crisis and that his physician, nurse or pharmacist would give him sympathetic interest as well as relief from pain. This situation has radically changed. We are now in a new era in which there is a strong current of public opinion on health matters. That opinion has developed with the rising educational levels of all our people. I t has been nurtured by the progressive fulfillment in recent decades of the A~erican dream of equal opportunity for all and by social and economic progress that is rapidly bringing to the vast majority a reasonable standard of living. Rapid scientific advances in the health field, together with the massive campaigns waged through newspapers, magazines, billboards, radio and television to bring these advances to the attention of the general public, have served to swell this current of public opinion. With these changes in our social order good health has become, in the public mind, a basic right and there has developed a heavy demand that the fruits of scientific advance be available to all our people. This demand has been given impetus by the growing strength of labor unions and their increasing attention to health and welfare provisions in their contracts with manage-
*
Adapted from address presented to the general session at the annual meeting of the AMERICAN PHARMACEUTICAL ASSOCIATION in New York City, August 3 , 1964.
18
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
ment. The increasing participation of lay community leaders on hospital boards of directors, on health planning councils and in such health-oriented organizations as heart associations, cancer societies, community chests and the Red Cross has been another factor. The most important manifestation of rising public interest in health matters is the increasing amount of health legislation enacted by Congress in recent years. As you know, the important legislation passed by Congress in 1963 was limited almost completely to the fields of health and education. The health legislation approved by Congress and by some of our state legislatures in recent years is in response to a public demand closely akin to that which has already produced major changes in the organization of health services in Norway, Sweden, Denmark, Great Britain and, more recently, Canada. It is folly for any of the health professions to attribute this legislation to the whims of politics. All of the health professions-and I am thinking especially of medicine, dentistry and pharmacy-should take a fresh reading on what the public wants and then provide leadership to achieve these objectives. Failure to provide this leadership will mean that the future courses of these professions will be charted for them by Congress and, to some extent, by state legislatures.
what the public wants What does the public want-and need-from the health professions in the United States? The answer is very simple. The public wants service available to all. It wants service of a good quality. It wants service at a price it can afford to pay. In these desires public opinion is strong and united. There are two other points on which public demands are a little less insistent, though public needs are just as great. Some professions must give due attention to the prevention of illness and the public wants the members of all professions to have compassion for their patients and a concern for the welfare of mankind. At first glance, it would appear that pharmacy is meeting these demands of the general public fairly well. With regard to availability of service, the corner pharmacy is to be found almost everywhere and, indeed, has become an American institution. Hours of operation are growing shorter, however. An article in a recent issue of the New York Times contained the disquieting information that many pharmacies in Manhattan are closed over Sunday, some without having a sign on their doors indicating where prescription service might be obtained.
cost of drugs Among the miracles of modern medicine which have been rapidly unfolding during the last 25 years are dramatic advances in drug therapy. These advances are due to the creative genius of our research scientists, some of whom are located in universities but many more of whom are now working in industrial research laboratories. This whole research effort is growing ra pidly in volume. As one might expect , there are some penalties associated with this wonderfully productive program. The sheer volume of new medications makes it difficult for physicians to develop a good working knowledge of many highpotency drugs. Many products on the market are near duplicates of other drugs. The pharmacist is faced with the problem of how many near duplicates t o stock; he recogni zes that a new " model" may be on the market soon and the old product may become part of an outdated inventory, the cost of which must be passed on to the pUblic. Many elements- the rising cost s of manufacturing, a huge industrial research program, the proliferation of drugs on the market and the problem of outdated inventory in the average pharmacy-have contributed t o the high costs of drugs prevalent today . The development of the best possible program of dru g therapy at the most equitable cost to the public is a matter which calls for the wisest direction from top leadership in the profession of pharmacy. It seems likely, too, that the federal govern ment will play a larger role in studying the operations of the pharmaceutical industry and its pricing practices.
level of practicing competence A question of growing interest to the general public in its dealings with all the health professions is the level of competence of individual practitioners 10, 20 or 30 years after their formal training has been completed. At a recent gathering of dental school deans and members of state boards of dental examiners, I pointed out that mass surveys, especially those related to induction of military trainees, have indica ted that the quality of work being rendered by some practicing dentists is very low indeed. After some discussion of the topic, I urged that the boards of dental examiners expand their work to include re-examination of practitioners at various st ages in their careers. It would then be up to the state boards and the schools, working together, to develop postgraduate educational programs to raise deficient practitioners up t o an adequate level of performance. The situation in the pharmaceutical 20
profession may not be analogous to that in dentistry but the question of the competence of practitioners at midcareer certainly deserves study.
hospital pharmacy The bulk of general hospital care in our country is rendered through voluntary, nonprofit community institutions. I am well aware from my own experience that these institutions, for the most part, are very much " nonprofit ;" indeed, they have great difficulties in making ends meet. At the national level, hospitals have adopted the principle of basing their overall charges for services rendered on the actual cost of those services. Most hospitals, however, make a substantial proflt on t heir pharmacy operation, some of which is due to the fact that manufacturers frequently give hospitals a better price on drugs. Hospital administrators contend that profits on their pharmacy operations onl y serve to balance losses in other departments and they further justify their charge system for drugs by saying that it keeps hospitals at peace with the local pharmacies . This hospital charge system for drugs, of course, occasionally penalizes very heavily those hospital patients whose therapy is based largely on drugs and means t hat some patil'nts who use few drugs actuall y pay less than the cost of their care. I have often wondered whether the general public would not be better and more economically served if hospitals across the land based their charges for drugs on actual cost of pharmaceutical service.
schools of pharmacy A conviction which I share with a number of university presidents and vice presidents for health affairs is that our schools of pharmacy generally have not responded well to their call to leadership during the last 20 years of great social and scientific change. Many schools of pharmacy have not considered issues of the t ype I have been discussing today or provided guidelines for the growth of the profession . These schools have in too many instances defaulted on a great opportunity for research development in the university setting. They have chosen to remain on their traditional course and, to a great degree, have become isolated from the other health professions and from the mainstream of university life. The skepticism with which the practitioners in some professions view the university faculties that trained them is reflected in the term "ivory-towered dreamers" which is occasionally applied to members of university faculties. Yet deep down most practitioners, whatever their field , realize that the ferment
Journal of th e AMERI CAN PHARMACEUTI CA L ASSOC IATION
in their own professional schools is a very precious thing; that from it comes a stimulus to the growth of t heir professions. I think all of us should be concerned about the relatively slow rate of ferment in many schools of pharmacy . These are some of my broader concerns about pharmacy. There are comparable problems in medicine, dentistry, nursing, public health and some of the auxiliary health professions.
trends in health services In expressing my concerns about pharmacy, I have suggested areas in which the profession is fallin g short of its broader responsibility to the American people. In the overall pattern of health services in our country, however, there are trends which, in my opinion, will help to solve some of the problems I have mentioned. These trends call for an increased contribution by the profession of pharmacy .
specialization in medicine The very rapid scientific advances made in all aspects of medicine since World War II are producing a revolution in the traditional pattern through which medical service is rendered. The time has long passed when the average physician could obtain a reasonable grasp of the scientiflc knowledge needed to serve patients in a comprehensive way. The swing to specialization in medicine started many years ago. The majority of youn ger physicians are specialists rather than general practitioners and among medical students the trend is definitely toward future specialty practice. There are spokesmen in the medical profession and a large body of people in the general public who decry this trend. They rue the fact that the general practitioner, who has functioned as counselor and friend as well as personal physician to his patient, is passing from the scene. Indeed, we must all admit that something is being lost by his passing. But the trend is clearly evident and the change-over is well along. When we examine this trend more closely, we find that the gains may far exceed the losses. The quality of sci entific medical practice now available to the public is far superior to that of the past. The average specialist is in a position to keep up with scientific advances in his specialty whereas keeping u p-to-date scien tificall y is a very difficult task for the general practitioner. The specialist , furthermore, can have a more satisfactory personal life with time scheduled for his fami ly, for public service in general and for postgraduate education . The general public faces a major problem, however, when medical specialists function in solo practice. With-
out the guidance of a family doctor, the average patient has to make his own diagnosis to know what specialist to see. Furthermore, the cost to the patient can be staggering when he has to see several specialists for a complex medical problem. A serious problem also confronts the average solo specialist, many of whose patients have medical conditions which are outside his field. His problem is that of deciding just when and to whom to refer those patients.
group medical practice It is to the advantage of the specialists, therefore, and certainly to the advantage of their patients for these physicians to function in close association with one another. Under such an arrangement consultation services are immediately available, some costs of medical practice are shared among several physicians and overall charges to patients can be kept within more reasonable bounds. It is noteworthy , too, that working in organized groups gives physicians a built-in stimulus to quality of service, since each is functioning under the watchful eyes of professional colleagues. Physicians, like pharmacists, are rugged individualists and the idea of practice in groups is foreign to many men-especially those of the older generation. Some form of group practice, however, is greatly needed by specialists, in their own interest as well as that of the patients they serve. There is a trend toward group practice among physicians. We see it manifested in the spread of doctors' buildings, sometimes housing the offices of several groups of physicians. We see it in a wide variety of medical care programs sponsored by labor unions and industrial concerns or related to these organizations. We see it in a variety of federal programs, including those of the Army, Navy and Veterans Administration, which serve millions of people. We see it in the faculties of some 85 schools of medicine scattered around the country. Perhaps most importan t of all, we see it as a growing program related to our community hospitals.
hospital as health center In this last connection, the progressive emergence of the nonprofit general hospital as a community health center was the principal subject of a talk I made to the deans of the American and Canadian schools of pharmacy at their annual meeting in August 1963. In that talk I called attention to the advantages of having the activities of physicians, nurses, public health workers and dentists centered around these community hospitals. Evidence of a notable trend in that direction is given by the huge
growth of emergency service and outpatient care being rendered through hospitals, by the increasing numbers of physicians who have full-time appointments in hospitals and by the progressive emergence of the community hospital as a center for postgraduate and continuation education for all types of health personnel. I predict that more and more of the pharmacy service in our country will be rendered through hospitals and that the hospital-related pharmacy will gradually replace the corner pharmacy as the primary source of drug service for patients.
implications of trends Although some of you may feel that I go too far in my predictions, the growing trend toward group medical practice in general and hospital-based group medical practice in particular is an inescapable fact. I think the meaning for pharmacy is also clear- an increasing number of professional pharmacies, without the auxiliary trappings of the corner or chain drugstore, are needed and should come into being. The result will be an increase in the number of pharmacists who will devote their full time to professional work and become real working partners with the physician. The pharmacist working in this professional setting will have more opportunity to influence the patterns of self-medication by patients and to develop the pharmacy as an instrument for education of the public in health matters. The hospital pharmacy setting also affords opportunities to reduce the cost of drugs to the pUblic. What, then, is the challenge facing American pharmacy? It is threefold~
the resolution of the problems I have been discussing
~
a full understanding of the trends in health care and of pharmacy's fu· ture role in this field ~
the development and progressive implementation of long-range objectives for the profession, looking toward the best possible service to the American people.
In conclusion, I would like to suggest four steps pharmacy should t ake in meeting this challenge.
commission to study problem There is a need and an opportunity to activate a major study commission t o make a careful analysis of the whole field of our discussion and to develop guidelines for pharmacy. Some of the larger philanthropic foundations such as the Ford Foundation, the Rockefeller Foundation, the Kellogg Foundation or the Commonwealth Fund might be interested in supporting such a study . They have paid little attention t o phar-
macy in the past, though some of them have been strong supporters of other health professions. Certainly the United States Public Health Service has a deep interest in this field and could probably help furnish money and direction for the study. Organized pharmacy should not be the sole sponsor of such a study, although several pharmacy organizations might serve as catalysts to activate the study, advise on the selection of members for the study commission and aid in every way possible in the accumulation of necessary data. What is needed is the broadest possible approach to the subject by a body of recognized competence that does not have a vested interest. In this connection, I was gratified to learn that preliminary steps are already being taken by leaders in the AMERICAN PHARMACEUTICAL ASSOCIATION to activate a study somewhat along the lines suggested here.
better leadership Some new mechanism must be found to supplement the good work being done by the American Council of Pharmaceutical Education in lifting our schools of pharmacy to a level of greater professional maturity and placing them in the mainstream of university life , both in their association with the other health professions and in their relation with many other components of their universities. This job , of course, belongs primarily to university presidents but leaders in the pharmacy profession have a role to play, too. As this transition in schools of pharmacy progresses, the profession will have a fresh and continuing source of leadership in charting the direction pharmacy should take in the years ahead . As I told pharmacy deansThere is a great need for more elder statesmen in the pharmacy field, well-informed professional men who have a deep interest in the whole field of health services to the general public but especially of the pharmacy component of those health services. These elder statesmen need to be active spokesmen in the public interest, not spokesmen for a professional or trade group and not spokesmen for an industry ... Pharmacy deans and faculty members are the proper people to fill this role. You are free to proclaim your honest convictions, indeed, have an obligation to do so as members of a university community. Some of you may feel that you are ready to assume leadership and be spokesmen but the questions and issues are so complex that you don't know what to advocate . I would like to point out that most of you have at hand within your parent universities (continued on page 38)
Vol. NS5, No. I, January 1965
21
challenge to pharmacy (continued from page 21) the means to find out the answers to many of the socio-economic-political questions which bear on pharmacy. You have not been taking advantage of these resources or possibly even been cognizant of them. There are likely faculty colleagues nearby in sociology, in economics, in business administration, in political science, in law, in city and regional planning (to name a few) who could make major contributions to studies of matters such as we have been considering ... However, the initiative for arousing the interest of your faculty colleagues and for planning the design of most studies, must come, in large part, from you. Finally, I urge that you work actively with other health schools and programs within your university to begin the creation in the teaching setting of the health team which must function later on in community practice. The first step in building a true health team lies in developing understanding and respect and cordial working relations among the numerous disciplines. A logical and proper place for this development is in the educational setting-the university medical center-where the various types of health personnel are trained and have their first working relationships with each other.
specialization in practice Serious consideration should be given to developing a new type of specialist in pharmacy practice-a man who would
have a master's or doctor's degree and would function, under normal circumstances, as the head of a professional pharmacy and be fully qualified and accepted as a fu ll consultant to physicians. Perhaps we already have the prototype of this new specialist among the current leaders in the hospital pharmacy field.
North Carolina school of pharmacy. The ancient religious tradition of tithing presupposes that 10 percent of one's income belongs to God. Is it unreasonable to think that pharmacists might devote a tenth of that 10 percent to the improvement of their profession for the benefit of mankind?
fund for pharmacy
conclusion
Finally, the planning and implementation of the overall program we have been discussing calls for a great deal of money. Much of this program must be carried out by the schools of pharmacy. Some of the money needed can come from the federal government, some from state governments, more from the major philanthropic organizations. In addition, I think a significant sum should come from the profession of pharmacy itself. I suggest that the leadership of this profession consider launching a crusade which calls for each pharmacist in the country to give one percent of his income each month to a fund for pharmacy. This money would match government and foundation funds to finance the continuing studies called for today, to lift the level of performance in our schools of pharmacy and to expand greatly the existing programs of extension education for pharmacy practitioners. This suggestion may seem at first like an idealistic dream. However, pharmacists of North Carolina have contributed more than $300,000 in recent years to a foundation supporting the University of
The overall job to be done hy the profession of pharmacy is awesome. In the face of this overwhelming challenge, you may well ask what you can do as individuals. Though the total job will be difficult, the task is by no means insurmountable. Many things must be done but they do not all need to be performed at the same time or by the same people or agencies. There is opportunity for a great deal of sharing of effort and mutual encouragement and stimulation . It may be of some comfort to you to know that the tasks facing medicine, dentistry, nursing and public health in the years ahead are equally great and that you will not be alone in your struggles. Furthermore, American medicine has a deep interest in the fu ture of pharmacy and should be a friend and ally in helping the pharmaceutical profession make its maximum contribution. As I grow older , I am more and more impressed by what one real leader can accomplish. The leadership of the profession of pharmacy can help make man y of these goals become realities five, ten or twenty years from now. •
state historians on assignment
S
where records can be stored. The five ultimate objectives of the program are to obtain the histories of community pharmacies, wholesale druggists, pharmacy manufacturers, colleges of pharmacy and state and county pharmaceutical associations in the respective states. The section hopes these objectives will be realized within five years through the efforts of the following state historiansGeorge w. Hargreaves, Alabama; Jesse F. Hurlbut, Arizona; T .S. Grosicki, Arkansas; Edward S. Brady, California; Curtis H . Wal· don , Colorado; Marvin H. Malone, Connecticut; Harry C. Zeisig. Delaware; Roy C. Darlington, District of Columbia; L.S. Gram· ling, Florida; Kenneth L. Waters, Georgia; Gail Stapleton, Idaho; Patrick F. Belcastro,
Indiana; Louis C. Zopf, Iowa; J. Allen Reese Kansas; Norman Franke, Kentucky; Edward J . Ireland, Louisiana; Merrill A . Hay, Maine; Benjamin F. Allen, Maryland; Herbert C. Raubenheimer, Massachusetts; Jane Rogan , Michigan; Charles V. Netz, Minnesota; Raymond J. Bennett, Mississippi; Phyllis M . Sarich, Missouri; Frank Pettinato, Montana; Robert D. Gibson, Nebraska; Chester L. Cochran, Nevada; Kenneth S. Fortier, New Hampshire; David l. Cowen, New Jersey; Isidore Greenberg, New York; Alice Noble, North Carolina; Clifton E. Miller, North Dakota; Charles O. Lee, Ohio; John B. Bruce, Oklahoma; Frederick Grill, Oregon; Arthur W_ Moore, Pennsylvania; Luis Torres Diaz, Puerto Rico; George Osborne, Rhode Island; Don A.F. Galgano, South Carolina; Kenneth Redman, South Dakota; Esther J .W. Hall, Texas; Robert V_ Peterson, Utah; Milton Neuroth, Virginia; Jack E. Orr, Washington; Glenn Sonnedecker, Wisconsin, and Fred l. Geiler, West Virginia.
session of the 1965 annual meeting in Detroit (Mich.) March 28-April 2. The board members-elect, who will serve for three-year terms, are Joseph H. Beckerman, chief pharmacist at the University of California Medical Center, and John W. Webb, director of pharmacy and
supplies at Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary in Boston. William W. Tester continues to serve as ASHP president through the 1965 meeting; Joseph A. Oddis continues as ASHP executi ve secretary.
ince the formation of the section on historical pharmacy in 1904 there has been occasional discussion regarding the appointment of state historians by either the local APHA chapter, the various colleges of pharmacy, the state boards of pharmacy or the state pharmaceutical association. In 1962 when Edward J. Ireland chaired the section, a resolution was adopted charging the chairman to appoint a state historian for the section in each of the 50 states. This resolution has been implemented by succeeding chairmen and at the present time there are 45 state historians who have accepted chairmanships. Appointees must be members of APHA and preferably teachers in colleges of pharmacy
ASH P election returns Francis Regis Kenna, director of pharmacy service at University of Chicago Hospitals and Clinics, is president-elect of the American Society of Hospital Pharmacists. Chosen by mail ballot, Kenna and two members of the board of directors will be installed at the final 38
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
F
a challenge
to
• american pharmacy'
by Henry T. Clark, Jr., MD
increasing demand for services Up until very recently, there was really no body of public opinion on health matters. There was simply the hope in the heart of every man that his needs would be met at the time of crisis and that his physician, nurse or pharmacist would give him sympathetic interest as well as relief from pain. This situation has radically changed. We are now in a new era in which there is a strong current of public opinion on health matters. That opinion has developed with the rising educational levels of all our people. I t has been nurtured by the progressive fulfillment in recent decades of the A~erican dream of equal opportunity for all and by social and economic progress that is rapidly bringing to the vast majority a reasonable standard of living. Rapid scientific advances in the health field, together with the massive campaigns waged through newspapers, magazines, billboards, radio and television to bring these advances to the attention of the general public, have served to swell this current of public opinion. With these changes in our social order good health has become, in the public mind, a basic right and there has developed a heavy demand that the fruits of scientific advance be available to all our people. This demand has been given impetus by the growing strength of labor unions and their increasing attention to health and welfare provisions in their contracts with manage-
*
Adapted from address presented to the general session at the annual meeting of the AMERICAN PHARMACEUTICAL ASSOCIATION in New York City, August 3 , 1964.
18
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
ment. The increasing participation of lay community leaders on hospital boards of directors, on health planning councils and in such health-oriented organizations as heart associations, cancer societies, community chests and the Red Cross has been another factor. The most important manifestation of rising public interest in health matters is the increasing amount of health legislation enacted by Congress in recent years. As you know, the important legislation passed by Congress in 1963 was limited almost completely to the fields of health and education. The health legislation approved by Congress and by some of our state legislatures in recent years is in response to a public demand closely akin to that which has already produced major changes in the organization of health services in Norway, Sweden, Denmark, Great Britain and, more recently, Canada. It is folly for any of the health professions to attribute this legislation to the whims of politics. All of the health professions-and I am thinking especially of medicine, dentistry and pharmacy-should take a fresh reading on what the public wants and then provide leadership to achieve these objectives. Failure to provide this leadership will mean that the future courses of these professions will be charted for them by Congress and, to some extent, by state legislatures.
what the public wants What does the public want-and need-from the health professions in the United States? The answer is very simple. The public wants service available to all. It wants service of a good quality. It wants service at a price it can afford to pay. In these desires public opinion is strong and united. There are two other points on which public demands are a little less insistent, though public needs are just as great. Some professions must give due attention to the prevention of illness and the public wants the members of all professions to have compassion for their patients and a concern for the welfare of mankind. At first glance, it would appear that pharmacy is meeting these demands of the general public fairly well. With regard to availability of service, the corner pharmacy is to be found almost everywhere and, indeed, has become an American institution. Hours of operation are growing shorter, however. An article in a recent issue of the New York Times contained the disquieting information that many pharmacies in Manhattan are closed over Sunday, some without having a sign on their doors indicating where prescription service might be obtained.
cost of drugs Among the miracles of modern medicine which have been rapidly unfolding during the last 25 years are dramatic advances in drug therapy. These advances are due to the creative genius of our research scientists, some of whom are located in universities but many more of whom are now working in industrial research laboratories. This whole research effort is growing ra pidly in volume. As one might expect , there are some penalties associated with this wonderfully productive program. The sheer volume of new medications makes it difficult for physicians to develop a good working knowledge of many highpotency drugs. Many products on the market are near duplicates of other drugs. The pharmacist is faced with the problem of how many near duplicates t o stock; he recogni zes that a new " model" may be on the market soon and the old product may become part of an outdated inventory, the cost of which must be passed on to the pUblic. Many elements- the rising cost s of manufacturing, a huge industrial research program, the proliferation of drugs on the market and the problem of outdated inventory in the average pharmacy-have contributed t o the high costs of drugs prevalent today . The development of the best possible program of dru g therapy at the most equitable cost to the public is a matter which calls for the wisest direction from top leadership in the profession of pharmacy. It seems likely, too, that the federal govern ment will play a larger role in studying the operations of the pharmaceutical industry and its pricing practices.
level of practicing competence A question of growing interest to the general public in its dealings with all the health professions is the level of competence of individual practitioners 10, 20 or 30 years after their formal training has been completed. At a recent gathering of dental school deans and members of state boards of dental examiners, I pointed out that mass surveys, especially those related to induction of military trainees, have indica ted that the quality of work being rendered by some practicing dentists is very low indeed. After some discussion of the topic, I urged that the boards of dental examiners expand their work to include re-examination of practitioners at various st ages in their careers. It would then be up to the state boards and the schools, working together, to develop postgraduate educational programs to raise deficient practitioners up t o an adequate level of performance. The situation in the pharmaceutical 20
profession may not be analogous to that in dentistry but the question of the competence of practitioners at midcareer certainly deserves study.
hospital pharmacy The bulk of general hospital care in our country is rendered through voluntary, nonprofit community institutions. I am well aware from my own experience that these institutions, for the most part, are very much " nonprofit ;" indeed, they have great difficulties in making ends meet. At the national level, hospitals have adopted the principle of basing their overall charges for services rendered on the actual cost of those services. Most hospitals, however, make a substantial proflt on t heir pharmacy operation, some of which is due to the fact that manufacturers frequently give hospitals a better price on drugs. Hospital administrators contend that profits on their pharmacy operations onl y serve to balance losses in other departments and they further justify their charge system for drugs by saying that it keeps hospitals at peace with the local pharmacies . This hospital charge system for drugs, of course, occasionally penalizes very heavily those hospital patients whose therapy is based largely on drugs and means t hat some patil'nts who use few drugs actuall y pay less than the cost of their care. I have often wondered whether the general public would not be better and more economically served if hospitals across the land based their charges for drugs on actual cost of pharmaceutical service.
schools of pharmacy A conviction which I share with a number of university presidents and vice presidents for health affairs is that our schools of pharmacy generally have not responded well to their call to leadership during the last 20 years of great social and scientific change. Many schools of pharmacy have not considered issues of the t ype I have been discussing today or provided guidelines for the growth of the profession . These schools have in too many instances defaulted on a great opportunity for research development in the university setting. They have chosen to remain on their traditional course and, to a great degree, have become isolated from the other health professions and from the mainstream of university life. The skepticism with which the practitioners in some professions view the university faculties that trained them is reflected in the term "ivory-towered dreamers" which is occasionally applied to members of university faculties. Yet deep down most practitioners, whatever their field , realize that the ferment
Journal of th e AMERI CAN PHARMACEUTI CA L ASSOC IATION
in their own professional schools is a very precious thing; that from it comes a stimulus to the growth of t heir professions. I think all of us should be concerned about the relatively slow rate of ferment in many schools of pharmacy . These are some of my broader concerns about pharmacy. There are comparable problems in medicine, dentistry, nursing, public health and some of the auxiliary health professions.
trends in health services In expressing my concerns about pharmacy, I have suggested areas in which the profession is fallin g short of its broader responsibility to the American people. In the overall pattern of health services in our country, however, there are trends which, in my opinion, will help to solve some of the problems I have mentioned. These trends call for an increased contribution by the profession of pharmacy .
specialization in medicine The very rapid scientific advances made in all aspects of medicine since World War II are producing a revolution in the traditional pattern through which medical service is rendered. The time has long passed when the average physician could obtain a reasonable grasp of the scientiflc knowledge needed to serve patients in a comprehensive way. The swing to specialization in medicine started many years ago. The majority of youn ger physicians are specialists rather than general practitioners and among medical students the trend is definitely toward future specialty practice. There are spokesmen in the medical profession and a large body of people in the general public who decry this trend. They rue the fact that the general practitioner, who has functioned as counselor and friend as well as personal physician to his patient, is passing from the scene. Indeed, we must all admit that something is being lost by his passing. But the trend is clearly evident and the change-over is well along. When we examine this trend more closely, we find that the gains may far exceed the losses. The quality of sci entific medical practice now available to the public is far superior to that of the past. The average specialist is in a position to keep up with scientific advances in his specialty whereas keeping u p-to-date scien tificall y is a very difficult task for the general practitioner. The specialist , furthermore, can have a more satisfactory personal life with time scheduled for his fami ly, for public service in general and for postgraduate education . The general public faces a major problem, however, when medical specialists function in solo practice. With-
out the guidance of a family doctor, the average patient has to make his own diagnosis to know what specialist to see. Furthermore, the cost to the patient can be staggering when he has to see several specialists for a complex medical problem. A serious problem also confronts the average solo specialist, many of whose patients have medical conditions which are outside his field. His problem is that of deciding just when and to whom to refer those patients.
group medical practice It is to the advantage of the specialists, therefore, and certainly to the advantage of their patients for these physicians to function in close association with one another. Under such an arrangement consultation services are immediately available, some costs of medical practice are shared among several physicians and overall charges to patients can be kept within more reasonable bounds. It is noteworthy , too, that working in organized groups gives physicians a built-in stimulus to quality of service, since each is functioning under the watchful eyes of professional colleagues. Physicians, like pharmacists, are rugged individualists and the idea of practice in groups is foreign to many men-especially those of the older generation. Some form of group practice, however, is greatly needed by specialists, in their own interest as well as that of the patients they serve. There is a trend toward group practice among physicians. We see it manifested in the spread of doctors' buildings, sometimes housing the offices of several groups of physicians. We see it in a wide variety of medical care programs sponsored by labor unions and industrial concerns or related to these organizations. We see it in a variety of federal programs, including those of the Army, Navy and Veterans Administration, which serve millions of people. We see it in the faculties of some 85 schools of medicine scattered around the country. Perhaps most importan t of all, we see it as a growing program related to our community hospitals.
hospital as health center In this last connection, the progressive emergence of the nonprofit general hospital as a community health center was the principal subject of a talk I made to the deans of the American and Canadian schools of pharmacy at their annual meeting in August 1963. In that talk I called attention to the advantages of having the activities of physicians, nurses, public health workers and dentists centered around these community hospitals. Evidence of a notable trend in that direction is given by the huge
growth of emergency service and outpatient care being rendered through hospitals, by the increasing numbers of physicians who have full-time appointments in hospitals and by the progressive emergence of the community hospital as a center for postgraduate and continuation education for all types of health personnel. I predict that more and more of the pharmacy service in our country will be rendered through hospitals and that the hospital-related pharmacy will gradually replace the corner pharmacy as the primary source of drug service for patients.
implications of trends Although some of you may feel that I go too far in my predictions, the growing trend toward group medical practice in general and hospital-based group medical practice in particular is an inescapable fact. I think the meaning for pharmacy is also clear- an increasing number of professional pharmacies, without the auxiliary trappings of the corner or chain drugstore, are needed and should come into being. The result will be an increase in the number of pharmacists who will devote their full time to professional work and become real working partners with the physician. The pharmacist working in this professional setting will have more opportunity to influence the patterns of self-medication by patients and to develop the pharmacy as an instrument for education of the public in health matters. The hospital pharmacy setting also affords opportunities to reduce the cost of drugs to the pUblic. What, then, is the challenge facing American pharmacy? It is threefold~
the resolution of the problems I have been discussing
~
a full understanding of the trends in health care and of pharmacy's fu· ture role in this field ~
the development and progressive implementation of long-range objectives for the profession, looking toward the best possible service to the American people.
In conclusion, I would like to suggest four steps pharmacy should t ake in meeting this challenge.
commission to study problem There is a need and an opportunity to activate a major study commission t o make a careful analysis of the whole field of our discussion and to develop guidelines for pharmacy. Some of the larger philanthropic foundations such as the Ford Foundation, the Rockefeller Foundation, the Kellogg Foundation or the Commonwealth Fund might be interested in supporting such a study . They have paid little attention t o phar-
macy in the past, though some of them have been strong supporters of other health professions. Certainly the United States Public Health Service has a deep interest in this field and could probably help furnish money and direction for the study. Organized pharmacy should not be the sole sponsor of such a study, although several pharmacy organizations might serve as catalysts to activate the study, advise on the selection of members for the study commission and aid in every way possible in the accumulation of necessary data. What is needed is the broadest possible approach to the subject by a body of recognized competence that does not have a vested interest. In this connection, I was gratified to learn that preliminary steps are already being taken by leaders in the AMERICAN PHARMACEUTICAL ASSOCIATION to activate a study somewhat along the lines suggested here.
better leadership Some new mechanism must be found to supplement the good work being done by the American Council of Pharmaceutical Education in lifting our schools of pharmacy to a level of greater professional maturity and placing them in the mainstream of university life , both in their association with the other health professions and in their relation with many other components of their universities. This job , of course, belongs primarily to university presidents but leaders in the pharmacy profession have a role to play, too. As this transition in schools of pharmacy progresses, the profession will have a fresh and continuing source of leadership in charting the direction pharmacy should take in the years ahead . As I told pharmacy deansThere is a great need for more elder statesmen in the pharmacy field, well-informed professional men who have a deep interest in the whole field of health services to the general public but especially of the pharmacy component of those health services. These elder statesmen need to be active spokesmen in the public interest, not spokesmen for a professional or trade group and not spokesmen for an industry ... Pharmacy deans and faculty members are the proper people to fill this role. You are free to proclaim your honest convictions, indeed, have an obligation to do so as members of a university community. Some of you may feel that you are ready to assume leadership and be spokesmen but the questions and issues are so complex that you don't know what to advocate . I would like to point out that most of you have at hand within your parent universities (continued on page 38)
Vol. NS5, No. I, January 1965
21
challenge to pharmacy (continued from page 21) the means to find out the answers to many of the socio-economic-political questions which bear on pharmacy. You have not been taking advantage of these resources or possibly even been cognizant of them. There are likely faculty colleagues nearby in sociology, in economics, in business administration, in political science, in law, in city and regional planning (to name a few) who could make major contributions to studies of matters such as we have been considering ... However, the initiative for arousing the interest of your faculty colleagues and for planning the design of most studies, must come, in large part, from you. Finally, I urge that you work actively with other health schools and programs within your university to begin the creation in the teaching setting of the health team which must function later on in community practice. The first step in building a true health team lies in developing understanding and respect and cordial working relations among the numerous disciplines. A logical and proper place for this development is in the educational setting-the university medical center-where the various types of health personnel are trained and have their first working relationships with each other.
specialization in practice Serious consideration should be given to developing a new type of specialist in pharmacy practice-a man who would
have a master's or doctor's degree and would function, under normal circumstances, as the head of a professional pharmacy and be fully qualified and accepted as a fu ll consultant to physicians. Perhaps we already have the prototype of this new specialist among the current leaders in the hospital pharmacy field.
North Carolina school of pharmacy. The ancient religious tradition of tithing presupposes that 10 percent of one's income belongs to God. Is it unreasonable to think that pharmacists might devote a tenth of that 10 percent to the improvement of their profession for the benefit of mankind?
fund for pharmacy
conclusion
Finally, the planning and implementation of the overall program we have been discussing calls for a great deal of money. Much of this program must be carried out by the schools of pharmacy. Some of the money needed can come from the federal government, some from state governments, more from the major philanthropic organizations. In addition, I think a significant sum should come from the profession of pharmacy itself. I suggest that the leadership of this profession consider launching a crusade which calls for each pharmacist in the country to give one percent of his income each month to a fund for pharmacy. This money would match government and foundation funds to finance the continuing studies called for today, to lift the level of performance in our schools of pharmacy and to expand greatly the existing programs of extension education for pharmacy practitioners. This suggestion may seem at first like an idealistic dream. However, pharmacists of North Carolina have contributed more than $300,000 in recent years to a foundation supporting the University of
The overall job to be done hy the profession of pharmacy is awesome. In the face of this overwhelming challenge, you may well ask what you can do as individuals. Though the total job will be difficult, the task is by no means insurmountable. Many things must be done but they do not all need to be performed at the same time or by the same people or agencies. There is opportunity for a great deal of sharing of effort and mutual encouragement and stimulation . It may be of some comfort to you to know that the tasks facing medicine, dentistry, nursing and public health in the years ahead are equally great and that you will not be alone in your struggles. Furthermore, American medicine has a deep interest in the fu ture of pharmacy and should be a friend and ally in helping the pharmaceutical profession make its maximum contribution. As I grow older , I am more and more impressed by what one real leader can accomplish. The leadership of the profession of pharmacy can help make man y of these goals become realities five, ten or twenty years from now. •
state historians on assignment
S
where records can be stored. The five ultimate objectives of the program are to obtain the histories of community pharmacies, wholesale druggists, pharmacy manufacturers, colleges of pharmacy and state and county pharmaceutical associations in the respective states. The section hopes these objectives will be realized within five years through the efforts of the following state historiansGeorge w. Hargreaves, Alabama; Jesse F. Hurlbut, Arizona; T .S. Grosicki, Arkansas; Edward S. Brady, California; Curtis H . Wal· don , Colorado; Marvin H. Malone, Connecticut; Harry C. Zeisig. Delaware; Roy C. Darlington, District of Columbia; L.S. Gram· ling, Florida; Kenneth L. Waters, Georgia; Gail Stapleton, Idaho; Patrick F. Belcastro,
Indiana; Louis C. Zopf, Iowa; J. Allen Reese Kansas; Norman Franke, Kentucky; Edward J . Ireland, Louisiana; Merrill A . Hay, Maine; Benjamin F. Allen, Maryland; Herbert C. Raubenheimer, Massachusetts; Jane Rogan , Michigan; Charles V. Netz, Minnesota; Raymond J. Bennett, Mississippi; Phyllis M . Sarich, Missouri; Frank Pettinato, Montana; Robert D. Gibson, Nebraska; Chester L. Cochran, Nevada; Kenneth S. Fortier, New Hampshire; David l. Cowen, New Jersey; Isidore Greenberg, New York; Alice Noble, North Carolina; Clifton E. Miller, North Dakota; Charles O. Lee, Ohio; John B. Bruce, Oklahoma; Frederick Grill, Oregon; Arthur W_ Moore, Pennsylvania; Luis Torres Diaz, Puerto Rico; George Osborne, Rhode Island; Don A.F. Galgano, South Carolina; Kenneth Redman, South Dakota; Esther J .W. Hall, Texas; Robert V_ Peterson, Utah; Milton Neuroth, Virginia; Jack E. Orr, Washington; Glenn Sonnedecker, Wisconsin, and Fred l. Geiler, West Virginia.
session of the 1965 annual meeting in Detroit (Mich.) March 28-April 2. The board members-elect, who will serve for three-year terms, are Joseph H. Beckerman, chief pharmacist at the University of California Medical Center, and John W. Webb, director of pharmacy and
supplies at Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary in Boston. William W. Tester continues to serve as ASHP president through the 1965 meeting; Joseph A. Oddis continues as ASHP executi ve secretary.
ince the formation of the section on historical pharmacy in 1904 there has been occasional discussion regarding the appointment of state historians by either the local APHA chapter, the various colleges of pharmacy, the state boards of pharmacy or the state pharmaceutical association. In 1962 when Edward J. Ireland chaired the section, a resolution was adopted charging the chairman to appoint a state historian for the section in each of the 50 states. This resolution has been implemented by succeeding chairmen and at the present time there are 45 state historians who have accepted chairmanships. Appointees must be members of APHA and preferably teachers in colleges of pharmacy
ASH P election returns Francis Regis Kenna, director of pharmacy service at University of Chicago Hospitals and Clinics, is president-elect of the American Society of Hospital Pharmacists. Chosen by mail ballot, Kenna and two members of the board of directors will be installed at the final 38
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION