- Email: [email protected]
Its Role in the Education of Clinically Oriented Pharmacists*
COMMUNITY PHARMACY PRACTICE
I;LINICAL PHARMACY= PATIENT INVOLVEMENT
Its Role in the Education of Clinically Oriented Pharmacistsl
By Sister Emmanf,Jel, DC
T
he edLication of pharmacists to meet the needs of society can b~ attained only through a careful blending of theoretical coursework and clinicaJ experiences whereby pharmacy students come to realize that their profession requires a service that is meaningful and in ke~ping with the times. Such a service requires a clinically oriented pharmacist who, regardless of his place of practice, will ~eek to provide patient-centered service, including - the use of patient profiles to intercept and prevent drug interactions; consultation services to patients, physicians qnd other members of the healthca re team; the development of drug histories; reporting of adverse drug reactions, ~ nd , fin ally, participation in community health educa.tion programs. This philosophy of a clinioal orientation in the education of pharmacists is important because the health care professions are currently experiencing the impact of mariy forces at work in society. These forces, expressing the dem ands of humanity, reason and justice, are impelling the health care professions , including pharmacy, to take a long, har9 look at present health care delivery patterns. The image of health care resulting from this self-study is not a pleasing sight, for it often appears to be one of a confusing mixture of uncoordinqted services characterized by a lack of continuity and unconcern for the recipients of health care. Those who acknowledge the basic problems opposing the delivery of adequate health care services today indicate that self-complacency, the safeguarding of individual interests and adherence to traditionalism have led the health professions often to adopt an attitude of
0 Presented to the. Academ y of General Practice of Pharmacy at the APhA annual meeting, Aprill4, 1970, Washington, D.C.
48
indifference and unconcern. As a result of these deficiencies, fragmentation in the delivery of health care services has taken place and services are doled out categorically without a genuine interest in th~ recipients of these services as persons who have social arid psychological needs as well as medical ones. Subsequent . government intervention, by way o(health care programs, has resulted in health care being no longer looked upon as a privilege, but rather as a right of all citizens. Awareness of the problems concerning the delivery of health care services in urban areas is being brought to the attention of the professions through well-documented reports such as that developed by the Health Task Force of the Urban Coalition.l Thus, as the government and consumers become more involved in establishing criteria for the delivery of health care, it is becoming obvious that each health care profession will remain the designer of its individual programs only if each develops high standards of coordinqted health care and provides services which are qccessible and available to all citizens. Within our own profession, we pharmacists have but to look at the incidence of adverse drug reactions-a glaring example of a lack of coordinqtion between pharmacy and the other health professions. It has been estimated that 1.5 million hospital admissions occur each year as a res-qlt of some misadventure with drugs2 and additionally, 15 percent of pati.e nts in hospitals experience an adverse drug reaction during the course of hospitalization.::~ These statistics are embarrassing because they force tlS to acknowledge that adverse drug reactions -many of them serious-are the result of the inadequacies and indifference on the part of the present health care team members. A large percent-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
age of drug reactions occurring are the result of drugs prescribed by physi· cians, dispensed by pharmacists and ad~ninistered by nurses. Oftentimes, adverse drug reactions occur because there is little or no effort made between the Vqrious professions, and within the individual professions, to establish preventative measures against harmful drug reactions. Within the pharmacy profession there is a tremendous need for community and hospital pharmacists to share and pool individual patient drug history data so that important drug and allergy information will be available wherever the patient is receiving medical care. Obviously, even before this stage we need to develop methods whereby a citizen will seek to ide!l-tify with one pharmacy in his community in order that he be assured continuity in the provision of pharmaceuqcal services. · Studies have shown that people most frequently choose a pharmacy be· cause of the convenience of its location. 4 As the public becomes more educated about the dangers associated with drug use, it will become more de· manding that a type of pharmaceutical service be provided which will assure the safe use of prescription and o-t-c medications. As community pharmacies develop to meet the real health care needs of society they will attract people for more important reasons than that stated previously. While there is a great need for patient-oriented pharmacists in institutional practice, there is an even greater need for such pharmacists in com· munity practice. If the void created by a lack of drug advisers is not fill ed by pharmacists, others will soon take over these functions and the pharma· cist will continue counting, pouring and typing labels in his role as a most over-educated technician . .
The Role of Pharmacy Education For many years pharmacy education has been somewhat complacent in producing pharmacists who were more product-oriented than patientoriented. For this reason, among others, the public looks upon many pharmacists as providers of a commodity rather than as providers of a much needed service. To change this image it appears necessary to recognize that the education of pharmacists and the well-being of society cannot be separated-to meet the needs of both, considerations for education and service must be planned and carried out together. In the past, education of pharmacists often failed to awaken a sense of concern and awareness of the health problems of the population. Students today have a unique need to express sincerity and are willing to work for a cause which appears worthy and meaningful to society. These students, however, must be presented the opportunity to encounter-with appropriate guidance-some of the glaring medical needs and problems of today's society. As far as pharmacy students are concerned, there is needed a wellbalanced combination of theoretical courses, interspersed with a variety of clinical experiences, which will sensitize these students to the needs of society and stimulate a desire to be of genuine service. Provision of this type of pharmacy education is based on the following broad goals1. To provide effective programs of
instruction and experience at the undergraduate, professional and graduate levels in humanistic, scientific and clinical areas to prepare students to meet the multifaceted needs of society. 2. To promote research programs of excellence in both basic and applied fields. Many of these research projects involve drug and health problems peculiar to an urban setting. 3. To achieve optimum interaction between the college of pharmacy and the community by providing educational services to the public in matters pertaining to drug use and abuse, and by offering consultation services to community pharmacies and health care institutions in regard to the provision of optimum pharmaceutical services to the public. As indicated in the first goal, at the undergraduate, professional and graduate levels, effective programs of Pharmaceutical education should include humanistic, scientific and clinical areas, including service aspects as well. To this end, students should receive courses in pathology, biopharmaceutics and in the social aspects of health care. In addition to these condition-
Sister Emmanuel, DC, is a member of the Daughters of Charity of St. Vincent de Paul and a registered pharmacist in New York, Connecticut, Florida, Virginia and Michigan. She is an assistant professor of clinical pharmacy at Wayne State University college of pharmacy and pharmacy consultant for Providence Hospital, Southfield, Michigan. Sister Emmanuel received her BS in pharmacy from St. John's University and her MS in pharmaceutical administration from Wayne State University. She is a m·ember of APhA, currently serving as a member of the Professional Affairs Committee, and is also a member of ASHP.
ing courses, students should be placed in situations where they have the opportunity to observe, and in some instances to assist conscientious practitioners who are attempting to bridge the gap between the reality and the availability of comprehensive pharmaceutical services. Pharmacy students, both undergraduate and graduate, need to be exposed to the many ramifications of pharmaceutical services that are characteristic of the seventies including the communication techniques involved in providing consultation services to all segments of the public. To thus reflect the health care needs of society in the educational programs of a college of pharmacy necessitates involvement on the part of faculty and students with the design and delivery of meaningful pharmaceutical services. This, in turn, involves face-to-face interaction of faculty and students with practicing pharmacists, other health care professionals and society itself. For years field work has been an accepted and essential part in the education of public health nurses and social workers who, through these type of experiences, were brought face-toface with people who needed their professional services. While there may be many pharmacists today who argue that the public is not interested in recetvmg consultation services from pharmacists, there are others who ardently believe that once the public experiences a sense of genuine concern on the part of pharmacists-a concern which can only be experienced by faceto-face communication-the public will just as eagerly seek and respect
the advice of the pharmacist as it now does other members of the health care team.
Community Pharmacy Pilot Program The community pharmacy clinical experiences offered to date in the pilot program at Wayne State University college of pharmacy have been at the graduate level. In September 1969, a group of seven advanced standing graduate students who were matriculating for a master of science degree participated in a pilot program referred to as "Research in Clinical Pharmacy." In this program each graduate student received clinical pharmacy experiences in both institutional and community pharmacy practice. As prerequisites, or co-requisites, the students involved were required to have courses in pathological states and processes, clinical pathology, clinical pharmacology, biopharmaceutics and biostatistics. The program development was based on the cooperation of four community hospitals, 14 community pharmacies, one county mental health clinic and more recently through the involvement of the college of pharmacy in the provision of services in a Model Cities Neighborhood program as shown in Table I (see below). Physicians and pharmacists cooperating in the program were contacted individually by the faculty coordinator of the program. The practicing physicians selected for participation in the program were primarily physicians involved in educational programs for medical interns and residents-physicians who had much to offer and who could be relied upon to involve the
TABLE I
Sites for Clinical Pharmacy Experiences Hospitals
g:~:~~~ ~~~~~~~~~~~: ~~;,a~~~~~~~).~t~::: :::::
::::::::: : : :::: ::::::::: ::::::: :: :: :: Pediatric (short-term, private, nonprofit) .... .... · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · Community pharmacies . ...... .... .. .. ...... · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · Model Cities Neighborhood program ................. · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · County mental health clinic ................................ · · · · · · · · · · · · · · · · · · · · · · · · · Total
Vol. NSll, No. 2, February 1971
i 1 1 1 1
20
49
TABLE II
Graduate Student Clinical Pharmacy Field Experiences Number of students involved. . . . . . . . . . . . . . . . . 7 Number of quarters per year. . . . . . . . . . . . . . . . . 3 Days per week for each student. . . . . . . . . . . . . . 1 Hours per quarter for each student..... . . . . . . . 85 Hours per three quarters for each student. . . . . . 256 (Community clinical pharmacy experiences 90 hours) (Hospital clinical pharmacy experiences 166 hours)
graduate pharmacy students in drugrelated discussions while participating in patient rounds. In the case of participating community pharmacies, onsite visits were made to each pharmacy to ascertain the type of experiences available and to provide a thorough explanation of the type of clinical experiences desired. The pilot program beginning in the fall of 1969 involved seven students for a total of three quarters (Table II, see above) . At the beginning of each
quarter an individualized schedule was presented to each student (Figure 1, see below). Each student spends one full day per week in obtaining clinical pharmacy field experiences and by the end of the program will accumulate 256 hours of experience, 90 hours of which . takes place in community pharmacies (Table II, see above). Of the 14 community pharmacies selected eight were apothecary-type pharmacies and six were of the gen-
FIGURE
eral type, including both independent and chain-type pharmacies (Table Ill, page 51). The 14 community pharmacies now serving as a base for graduate students' clinical pharmacy experiences were selected on the availability of either a unique service or a variety of services which would serve to broaden the students' clinical experiences-and on the willingness of the owner and pharmacists staffing the community pharmacy-to cooperate with the clinical pharmacy program. Pharmacy students participating in the pilot program are assigned an average of 90 hours (ranging 7 4-102 hours) of clinical pharmacy experiences in the various community pharmacies (Table IV, page 51). Community Pharmacy Experiences In community pharmacies as well as in hospitals the intent is to provide experiences which will not only assist
1
TO: Thomas Hunter, RPh FROM: Sister Emmanuel, Assistant Professor of Clinical Pharmacy SUBJECT: Schedule for Clinical Pharmacy Research-PHA 0895-Fall Quarter DATE: September 7, 1969 DAY OF EXPERIENCE: Thursday
Date
Time
Location of Experience
Type of Clinical Experience
Report To:
9-25-69
9 :OQ-10 :00 a.m. 10 :OQ-12 :00 noon 1 :3D-4:30p.m.
Detroit General Hospital Detroit General Hospital Tri Medico Pharmacy
Rheumatoid teaching session Rheumatology O.P. clinic Nursing home consultation
Brinkman, MD " " H. Gold, RPh
10-2-69
9 :OQ-10 :00 a.m. 10 :OQ-12 :00 noon 1 :3Q-4 :30 p.m.
Detroit General Hospital Detroit General Hospital Tri Medico Pharmacy
Rheumatoid teaching session Rheumatology O.P. clinic Nursing home consultation
Brinkman, MD H. Gold,
10-16-69
8 :OQ-10 :00 a.m. 11 :OQ-11 :30 a.m. 12 :OQ-1 :00 p.m. 2 :3Q-5 :00 p.m.
Providence Hospital Providence Hospital Providence Hospital Tri Medico Pharmacy
Internal medicine and cardiology rounds Necropsy review Tumor board case presentation Nursing home consultation
Berman, MD " " Pfeifer, MD H. Gold, RPh
10-23-69
8 :OQ-10:00 a.m. 11 :OQ-12 :00 noon 12 :OQ-1 :00 p.m. 2 :3Q-5 :00 p.m.
Providence Hospital Providence Hospital Providence Hospital Tri Medico Pharmacy
Internal medicine and cardiology rounds Necropsy review Tumor board case presentation Nursing home consultation
Berman, MD " " Pfeifer, MD H. Gold, RPh
10-30-69
8 :OQ-10 :00 a.m. 10:00-11 :30 a.m. 1 :3Q-4 :30 p.m.
Providence Hospital Providence Hospital Tri Medico Pharmacy
G.I. rounds Teaching rounds in medicine Nursing home consultation
Gelzayd, MD Zobl, MD H. Gold, RPh
11-6-69
8 :OQ-10 :00 a.m. 10 :OQ-11 :30 a.m. 1 :3Q-4 :30 p.m.
Providence Hospital Providence Hospital Nottingham Pharmacy
G.I. rounds Teaching rounds in medicine Rx and OTC consultation
Gelzayd, MD Zobl, MD M. Gowman, RPh
11-13-69
9 :OQ-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4 :30 p.m.
Nottingham Pharmacy Detroit General Hospital Detroit General Hospital
Rx and OTC consultation Dermatology rounds with junior medical students Cardiology lecture by residents
M. Gowman, RPh Rudner, MD Schatz, MD
11-20-69
8 :3Q-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4:30 p.m.
Cunningham's Pharmacy Detroit General Hospital Detroit General Hospital
Rx and OTC consultation Dermatology rounds with junior medical students Cardiology lecture by residents
A. Koorhan, RPh Rudner, MD Schatz, MD
* 12-4-69
10 :3Q-ll :30 a.m. 1 :3Q-4:30 p.m.
V.A. Hospital, Allen Park Cunningham's Pharmacy
Present dermatology lecture to resident staff Rx and OTC consultation
Duke, Resident MD A. Koorhan, RPh
12-11-69
8 :3Q-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4 :30 p.m.
Cunningham's Pharmacy Detroit General Hospital Detroit General Hospital
Patient Rx and OTC consultation Dermatology rounds with medical students Cardiology lecture by residents
A. Koorhan, RPh Rudner, MD Schatz, MD
,
,,
~Ph
<~ Assi~nment-Contact Dr. Duke, Senior Medical Resident at Detroit General Hospital, for subjects to be included in preparing lecture on "PsychopharmacologiCal Agents Used in Dermatology." Outline to be reviewed with instructor prior to presenting lecture. Submit two copies of lecture outline in detail.
50
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
future practitioners to serve at their greatest potential, but those which will affect students in such a way that they more easily will acquire the intellectual and moral strengths to make correct value judgments in the provision of consultation services. To this end, students are assigned community pharmacy experiences wherein they will be provided the opportunity to · offer consultation services to individuals and to families in regard to pre"' scriptions, o-t-c medications, surgical supplies and appliances, and where they can assist in the development and use of patient profiles. Particular attention is given to developing concepts which encourage group practice and a family pharmacist type of service.
TABLE III
Pharmacies in Clinical Pharmacy Program Classified by Type of Service Provided Apothecary pharmacy (prescriptions, o-t-c's). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apothecary pharmacy primarily serving health care facilities. . . . . . . . . . . . . . . . . Apothecary pharmacy with diagnostic lab............. . . . . . . . . . . . . . . . . . . . . . General-type pharmacies (prescriptions, o-t-c's, surgical supplies, accessories and sundries) Independent type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chain type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total
Again this week I was able to mingle with the patients in front of the prescription counter. I have gained more confidence although at first, I must admit, I was somewhat in doubt as to whether I had anything to offer these people. I am now convinced that I have contributed something to their needs and can ascertain this by the surprised and appreciative comments made to me by patients. I learned that people are greatly in need of consultation. Most people haven't the faintest notion as to how important it is to take their medication or, in
5 1
14
TABLE IV
Hours of Community Clinical Pharmacy Experiences per Student Types of Pharmacies
Average Number Hours per Student/3 Quarters
Independent community pharmacy Chain pharmacy Pharmacy serving nursing homes Pharmacy with diagnostic laboratory Pharmacy with surgical supplies Pharmacy in medical building Community mental health clinic
8-12 12-16 14-18 12-16 12-16 12-16 4-8
General Type Pharmacies
The five independent type and one chain type pharmacies were selected from areas of the city which provided service to either low, average or highincome persons. In these pharmacies students received prescription orders ·from the patients and consulted with them both before and after the prescription orders were dispensed. Students, however, were not involved in the actual dispensing of the prescription orders. In the chain pharmacy, located in a disadvantaged area, students spent 12-16 hours becoming acquainted with the health problems of the poor as well as in gaining insight into the economic, social and psychological problems of the disadvantaged. The independent type . pharmacies provided students the opportunity to contrast various types and degrees of professional practice, to observe and personally experience the frustrations of providing patient-oriented services and, finally, to formulate methods of achieving clinical roles in community practice. Students' reactions to each experience were captured on a "Clinical Experience Report" (Figure 2, page 52) which was submitted to their clinical coordinator following each clinical pharmacy experience. Typical student comments included-
5 1 2
Total No. Hours 74-102
some instances, how dangerous some of the o-t-c preparations very likely could be to them. I learned that people are most appreciative of the time which I spent talking with them. I talked to numerous other patients, mostly about how to take their medications. Several people just wanted to talk and I found this interesting from the point of view that this is the exact way to build up respect and a professional acceptance from the people. This type of experience also helps one develop an all-around knowledge of the patient. I found this experience fairly rewarding.
Most students found it difficult, at first, to relate to patients, especially those from disadvantaged areas, and had to be encouraged and supported in gaining this type of experience. Without a doubt, however, this type of experience served to sensitize the students to the specific problems and needs of the disadvantaged and assisted the students in developing an attitude of sincere concern and respect which often made it necessary that the students attempt to overcome themselves in order to be of service.
Nursing Homes During their orientation to nursing homes students consulted with nursing home ~dministrators, made rounds on the nursing units where they reviewed patient records and answered drug-related questions from physicians and nurses. The community pharmacist
participating in this area assigned each student four out of the 18 nursing homes he was servicing in which to present a lecture on drugs used in specific clinical situations. Each student also was responsible for preparing two clinically oriented pharmacy bulletins for distribution to the nursing homes involved in the program. Additionally, working with an on-site pharmacy which was participating in the program, several stude~ts spe~t a considerable amount of their own time in providing extra consultation services which involved the setting up of a patient drug profile system and an extensive drug incompatibility file in one of the 200-bed nursing homes. Students reacted positively to their experience of providing lectures in th~ nursing homes although they found It difficult to adjust the level of their lectures to an assorted audience of nurses, practical nurses and aides. By means of patients' chart reviews ~nd through conversation with the nursmg staff and community pharmacists servicing these nursing homes, students gained insight as to the special drug problems of nursing home patients as expressed by several of the following comments/ am becoming more and more convinced that the pharmacist should play an important role in the management of drug therapy in the nursing home. Since the attending physicians make rounds less frequently than in a hospital, there is a greater need here for a medication consultant. Vol. NSll, No. 2, February 1971
51
FIGURE
2
Clinical Experience Report for PHA 0895-Research in Clinical Pharmacy STUDENT Thomas Hunter, RPh DATE OF EXPERIENCE 12-11-69' TIME LOCATION Cunningham's ~cy (Hospital or
8:\30-1'1.:30 a.m.
~harmacy)
TYPE OF EXPERIENCE Patient Consultatiop, on 'Rx· $<1 OTC Items (Patient Rounds, D.P.D., Consultation to /fol,l:I.," etc
PHYSICIAN OR PHARMACIST Mr. Koohan 1 ,RP:h a ' SUPERVISING E:x;PElUENCE . . 4 DIRECTIONS: Submit two typed clinical experiepce relilort forms sff)Peao of time spent in each clinical, experience. 1. Describe briefly what was provided through thfS· ~lini This was a unique experience as I was given the
tion order from ·the patient and returning the with advice on how to take the medication, p,re 2. What did you learn? · r learned that people really need this typ hav~n't the faintest concept of the >:il,nport supposed to. Patients don't realize that urine, or that some drugs should be taken. 3. What contribution did you 711ake concl!tfling I discussed the above type of. information appreciative. I demonstrat~.d to one.w,patient mistometer. I explained to• another ' patient ~, antacid along with aspirin. One 'patient request~d ad>fice op tion and I made specific r~commend~tions. ,NO'w that I am operation I .am beginning to feel more com£ortaple. ' 6 4. Comments: .. ,, I definitely feel that such a role is necessary fo~3lle elin,icallY, ori tainly appears to be most valuable to those patien't$ ar.~
who
This experience provided me an opportunity to orient myself to the requirements imposed upon the program of pharmaceutical services in nursing homes. This experience afforded me an opportunity to review patient charts and to be available for consultation. This type of experience is worthwhile in that it prepares one, or, at least gives the clinical pharmacist experience in presenting lectures thereby enhancing his background as an educator. In situations of this type the liaison between the nursing home nurse and the consultant pharmacist is strengthened allowing a somewhat greater degree of freedom in the exchange of knowledge concerning patient care and drug therapy. This week I spent some additional time on the nursing unit to evaluate the type of medication records which the nursing home keeps. This was done for the purpose of making recommendations for the patient profile which the pharmacy has definitely decided to provide.
Diagnostic Lab Both of the pharmacies with diagnostic labs participating in the pilot program were managed by registered pharmacists. Students, therefore, were not only provided a unique opportunity to become familiar with the types and significance of tests used in diagnosing a variety of clinical conditions, but also, during the three to four afternoons spent in this area, had the opportunity to correlate prescription 52
orders with diagnostic test orders which were presented by patients with specific medical problems. Students found the opportunity to research and discuss drugs which interfere with particular diagnostic tests both challenging and rewarding. Several students, however, were of the opinion that the experience could have been more beneficial if patients with clinical problems could be followed from the physi~ian's office through the diagnostic testing procedure to the time of final diagnosis. Pharmacists practicing in these prescription and diagnostic labonitories were most responsive to student discussions on drug-drug and drugdiagnostic test incompatibilities ahd together with the students worked out systems of reporting incompatibilities to physicians. Student response to this experience is indicated by the following commentsDuring this experience the pharmacist in charge and I discussed a reporting system that could be used to notify physicians of medications which may alter laboratory results. A [so, we discussed the information which would have to be on hand in order to detect these incompatibilites. Discussed the need to correlate laboratory test results with patient drug regimes. Noted how difficult it is to represent to a physician that an abnormal test value may be due to drugs. Very interesting. Might be somewhat more beneficial, however, if we could
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
take a patient with some pathological problem from the initial interview with the physician, through the laboratory tests to the final diagnosis. I would find it interesting if there was a laboratory-oriented course in which we discussed the details involving the~e laboratory tests, the principles behind them, the inherent problems with them, what factors affect them, etc . ... and also actually perform these tests ourselves so that we may become more intimately acquainted with these tests. I feel I could also use more detailed pathology concerning the individual laboratory tests.
Surgical and Health-Related Items This clinical experience in a pharmacy specializing in surgical and health-related items provided the opportunity to become familiarized with a large number of health and surgical supplies and accessories, to consult with patients on these items and to assist in the provision of home care services. For most students, this experience clarified the need for a pharmacist consultant service in this area. One student stated, "A drug profile should be established on patients using colostomy or ileostomy appliances in order to identify drugs which might induce specific problems in these patients." Most students reacted positivelyInteresting to see how a poorly defined system of health care exists for the post-hospital colostomy patient. Patients and pharmacists (since pharmacists are generally the first asked) need to know where to procure these items and how they should be used properly. During this experience I was privileged to observe about two hours of consultation with a recent colostomy patient who had an ostomy operation less than ten days ago. It was interesting to observe the rapport that was developing between the pharmacist and the patient. I became aware of the pharmacists reasons for selling and renting surgical supplies; that is, the pharmacist is attempting to fill the present gap between care of the patient in the hospital an.tj, follow-up care at home.
Medical
~uilding
Pharmacy
During this experience students spent their time observing and providing drug therapy consultation services in physicians' offices within the medical building. Appointments to consult with physicians in their offices were made in advance and on the afternoon of each assignment the student involved consulted with at least three to four physicians. Physicians practicing the same specialty, i.e. pediatricians, were, as far as possible, seiected for the same afternoon thus permitting students to prepare, dis-
and I observed four patients interviewed. I observed over 15 patients who were mostly children from one month to 13 years of age. For each child, I was briefed on the history and then introduced to the treatment prescribed. I was also given an explanation for the rationale for prescribing certain medications for specific age groups.
Goals to Be Derived Graduate pharmacy student discusses current drug therapy with a group of nursing home personnel. Arrangements for this experience were set up through a community pharmacy serving the nursing home.
In the Wayne State University college of pharmacy program, community pharmacists located in medical buildings arrange for pharmacy students to consult with physicians practicing within the same building.
tribute and discuss handout material on drug incompatibilities, etc. which would be of particular interest to a given group of physician specialists. Observations in the physicians' offices provided insight as to typical symptoms of disease, methods of diagnosing and an opportunity to learn physicians' reasons for prescribing certain drugs in preference to others which the student might have learned were equally, or perhaps more, effective in certain situations. While physicians responded to the presence of the student as an observer, there was a much less positive response when students were given appointments to discuss drug therapy with physicians. In this latter role some physicians and their office personnel were inclined to react to the students in the same fashion as they would to representatives of drug manufacturing firms primarily because they had · no prior experience with pharmacists in this new role. This experience helped the students to realize that the pharmacy practitioner's role as a communicator of health care information with other health care practitioners ca11s for as much psychological finesse, if not more, than between a pharmacist and
a person who seeks advice regarding personal health care problems. Student comments bear out both physician and student reactions to the programBoth physicians thanked me for talking to them and asked me to call on them again. In each office I did not wait at all. I talked with one physician for ten minutes and another for one-half hour (clinical pharmacy, etc.). For this type of consultation the pharmacist must be relevant. I was not able to complete my talk as the physicians asked me many questions on other subjects. This week was not as successful as the first week. I did not have to wait long to see the physicians but found the physicians too busy. One physician admitted that drug interactions wer,e a problem and then dismissed me. A second physician agreed that something should be done and insisted that he was doing it. Consulted with three physicians. I discussed what drug interactions are, their significance, types of interactions and the role of the pharmacist. I then discussed some of the newer drug reactions. I was placed in the office of a physician who specialized in ophthalmology. We talked of his philosophy of drug use
What is to be achieved through the involvement of community pharmacies in the development of clinically oriented pharmacy students? The principal value of these experiences appears to be that they develop in the students empathy for people, a very important consideration, because this, in turn, urges students to seek out and participate in providing those services which offer a distinct contribution to society. In developing educational programs it is well to keep this goal in mind because all the clinical knowledge in the world is worthless to a pharmacist in direct contact with the public unless he first has an abiding concern for his fellow man. It is concern for others that impels man to action. In community pharmacy practice there exists perhaps more challenging opportunities than in a hospital to apply the principles of drug monitoring, to offer consultation services, to assist in the detection and prevention of adverse drug reactions and to educate the public to seek drug information from proper sources. Conclusion
For several reasons, as might be expected, students did not react as positively to clinically oriented community pharmacy experiences as those provided within a hospital environment. Both students and community pharmacists involved in the experiences were somewhat uncertain as to the objectives to be sought and the ultimate value which students were to receive from each experience. Undoubtedly, because all of the graduate students involved were hospital pharmacists, it was logical to expect less interest in community pharmacy aspects of clinical pharmacy practice. An informal discussion period held each quarter-during which students related their experiences and the instructor re-emphasized the objectives sought in each community experience -did not prove adequate. There appears to be a much greater need for more frequent discussion periods which not only would better prepare students for each experience but would permit the instructor to more effectively correlate the philosophy behind (continued on page 63) Vol. NSll, No. 2, February 1971
53
community, dedicated health professionals, and intensive participation and involvement of the residents being served. The Comprehensive Health Center provides an effective way to maximize the utilization of scarce dollar resources. The Neighborhood Health Center enables all individuals to be integrated into the mainstream of medical care. The center enables the under-utilized pharmacist to apply his training and knowledge, in addition to participating as a viable member of the health team. The health center also serves as a training facility in which individuals can be trained in such new roles as family ·health workers, medical assistants, pharmacy technicians and mental health aides. The center therefore will not only provide substantive jobs but also will provide upward job mobility for area residents. The various "help" programs thus become an effective tool in reducing and finally in eliminating one cause of poverty. The Neighborhood Health Center provides the setting whereby effective team relationships can be implemented between health professionals and individuals desiring services.
In conclusion, it can be stated that the Neighborhood Health Center concept has been accepted as a relatively efficient mechanism of delivering highquality comprehensive health services to those in need. The era of pharmacists remaining within the "four walls" of their pharmacies in order to be successful is now in the past. Today, pharmacists are rendering comprehensive pharmacy health service to patients and health professionals outside their traditional "four walls." This has contributed toward changing the professional role of pharmacists. At the present time and even more so in the future, pharmacists will become increasingly oriented toward the health needs of the community. The "action pharmacists" have been given the opportunity to render complete pharmaceutical service to individuals who have thought of health care with low priority. Concurrently, all pharmacists must deliver quality complete pharmaceutical service to the rest of our society if the profession of pharmacy is to remain a viable member of the health team of the present and the health delivery system of the future. •
Community Pharmacy
In such well-balanced programs, pharmacy students would be given the opportunity to apply their knowledge in a fashion in keeping with the needs and demands of society. What the impact of the present program will have on pharmacy practitioners and the upgrading of pharmacy practice only time will tell. For the present, however, the effect on graduate students and pharmacy practitioners has-in a majority of casesbeen most rewarding. Much meaningful dialogue has taken place and a keen interest on the part of students and practitioners to apply principles of clinical pharmacy practice has been witnessed in many instances. •
(continued from page 53)
the development of the program. There is a need also to correlate clinical experiences more closely with scientific course work, including course work on public health and sociological courses, as well as scientific courses such as pharmacology and medicinals. Finally, participating community pharmacists should be brought more effectively into the planning and continuous redesign of field experience programs. Predicting the Future
What the future holds for pharmaceutical education is a challenging consideration. Through close association with other members of the patient care team in both hospital and community pharmacy practice there is evolving a greater respect among the professions based on a new awareness of each profession's problems, contributions and · needs. Hopefully, in time the pharmacy curriculum will be so adjusted that undergraduate students will spend at least the last six months of their formal education in a collegeformulated clerkship program. Ideally, this type of clerkship will be accepted by the boards of pharmacy in each state in place of the usual internship programs. In well-designed and controlled college of pharmacy clerkship programs, students would rotate between hospitals and community pharmacies to obtain clinical pharmacy and practical dispensing experiences.
References 1. Health Task Force of the Urban Coalition, Rx For Action, A report prepared by the Health Task Force of the Urban Coalition, Washington, D.C. (1969) 2. Novitch, Mark, Changing Patterns in the Delivery of Pharmaceutical Services as Viewed by a Physician, Summary repo·rt prepared by The University of California school of pharmacy from a presentation at the School of Pharmacy Faculty Conference (April 1-2, 1969) San Francisco, The University of California school of pharmacy (1969) 3. Cluff, L.E.; Seidl, L.G., and Thornton, G.F ., "Epidemiological Studies of Adverse Drug Reactions," Am. J. of Public Health, 55 (Aug. 1965) 4. Gardner, Vincent R., Changing Patterns in the Delivery of Pharmaceutical Services as Viewed by a Pharmacist, Summary teport prepared by The University of California school of pharmacy from a presentation at the School of Pharmacy Faculty Conference (April 1-2, 1969) San Francisco, The University of California school of pharmacy (1969)
Pharmacist Cites Team Effort The importance of a good pharmacist-
nursing relationship in the care of elderly patients cannot be overemphasized, says APhA member Peter Bruno (above), staff pharmacist at the Brookwood Convalescent Center in Des Plaines, Illinois. Also, the pharmacist is available at all times to consult with the physician concerning various drugs, drug incompatibility and drug interaction. Pharmacist Bruno is able to check with the physician, as needed, to confirm the dosage of a particular drug or the length of time which it is to be taken. Drugs prescribed by the physician have an automatic stop order after a specified period of time. If the drug is to be continued the physician must issue a new order. "It is gratifying to see the results of the physician-nurse-pharmacist team effort," Bruno said. "If, for example, a drug isn't doing the job it should be doing, the nurse calls it to my attention. I, in turn, notify the physician and he can change the drug or the dosage. This type of problem is prevalent in the antibiotics . . . what's good for one patient is not necessarily the :right drug for another." Since joining the staff at Brookwood, Bruno has ins1tituted several of the latest methods of drug control. One of these is the floor control system in which an account slip is pulled from a master form each time a drug is dispensed. This system is checked three times each day since the head nurses validate the orders at the end of each tour of duty. The system aids in narcotic control, helps in maintaining an accurate drug inventory and is a great friend of the patient since he or she is charged only for the drugs that are dispensed. The other method of drug control is the unit dose. The drugs come in a one-day supply or as a single dose, giving the pharmacist complete control of his drug stores. The drugs cannot lose their vitality and they cannot become contaminated since only those that are to be used immediately are available in the small, sealed container. Vol. NSll, No. 2, February 1971
63
I;LINICAL PHARMACY= PATIENT INVOLVEMENT
Its Role in the Education of Clinically Oriented Pharmacistsl
By Sister Emmanf,Jel, DC
T
he edLication of pharmacists to meet the needs of society can b~ attained only through a careful blending of theoretical coursework and clinicaJ experiences whereby pharmacy students come to realize that their profession requires a service that is meaningful and in ke~ping with the times. Such a service requires a clinically oriented pharmacist who, regardless of his place of practice, will ~eek to provide patient-centered service, including - the use of patient profiles to intercept and prevent drug interactions; consultation services to patients, physicians qnd other members of the healthca re team; the development of drug histories; reporting of adverse drug reactions, ~ nd , fin ally, participation in community health educa.tion programs. This philosophy of a clinioal orientation in the education of pharmacists is important because the health care professions are currently experiencing the impact of mariy forces at work in society. These forces, expressing the dem ands of humanity, reason and justice, are impelling the health care professions , including pharmacy, to take a long, har9 look at present health care delivery patterns. The image of health care resulting from this self-study is not a pleasing sight, for it often appears to be one of a confusing mixture of uncoordinqted services characterized by a lack of continuity and unconcern for the recipients of health care. Those who acknowledge the basic problems opposing the delivery of adequate health care services today indicate that self-complacency, the safeguarding of individual interests and adherence to traditionalism have led the health professions often to adopt an attitude of
0 Presented to the. Academ y of General Practice of Pharmacy at the APhA annual meeting, Aprill4, 1970, Washington, D.C.
48
indifference and unconcern. As a result of these deficiencies, fragmentation in the delivery of health care services has taken place and services are doled out categorically without a genuine interest in th~ recipients of these services as persons who have social arid psychological needs as well as medical ones. Subsequent . government intervention, by way o(health care programs, has resulted in health care being no longer looked upon as a privilege, but rather as a right of all citizens. Awareness of the problems concerning the delivery of health care services in urban areas is being brought to the attention of the professions through well-documented reports such as that developed by the Health Task Force of the Urban Coalition.l Thus, as the government and consumers become more involved in establishing criteria for the delivery of health care, it is becoming obvious that each health care profession will remain the designer of its individual programs only if each develops high standards of coordinqted health care and provides services which are qccessible and available to all citizens. Within our own profession, we pharmacists have but to look at the incidence of adverse drug reactions-a glaring example of a lack of coordinqtion between pharmacy and the other health professions. It has been estimated that 1.5 million hospital admissions occur each year as a res-qlt of some misadventure with drugs2 and additionally, 15 percent of pati.e nts in hospitals experience an adverse drug reaction during the course of hospitalization.::~ These statistics are embarrassing because they force tlS to acknowledge that adverse drug reactions -many of them serious-are the result of the inadequacies and indifference on the part of the present health care team members. A large percent-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
age of drug reactions occurring are the result of drugs prescribed by physi· cians, dispensed by pharmacists and ad~ninistered by nurses. Oftentimes, adverse drug reactions occur because there is little or no effort made between the Vqrious professions, and within the individual professions, to establish preventative measures against harmful drug reactions. Within the pharmacy profession there is a tremendous need for community and hospital pharmacists to share and pool individual patient drug history data so that important drug and allergy information will be available wherever the patient is receiving medical care. Obviously, even before this stage we need to develop methods whereby a citizen will seek to ide!l-tify with one pharmacy in his community in order that he be assured continuity in the provision of pharmaceuqcal services. · Studies have shown that people most frequently choose a pharmacy be· cause of the convenience of its location. 4 As the public becomes more educated about the dangers associated with drug use, it will become more de· manding that a type of pharmaceutical service be provided which will assure the safe use of prescription and o-t-c medications. As community pharmacies develop to meet the real health care needs of society they will attract people for more important reasons than that stated previously. While there is a great need for patient-oriented pharmacists in institutional practice, there is an even greater need for such pharmacists in com· munity practice. If the void created by a lack of drug advisers is not fill ed by pharmacists, others will soon take over these functions and the pharma· cist will continue counting, pouring and typing labels in his role as a most over-educated technician . .
The Role of Pharmacy Education For many years pharmacy education has been somewhat complacent in producing pharmacists who were more product-oriented than patientoriented. For this reason, among others, the public looks upon many pharmacists as providers of a commodity rather than as providers of a much needed service. To change this image it appears necessary to recognize that the education of pharmacists and the well-being of society cannot be separated-to meet the needs of both, considerations for education and service must be planned and carried out together. In the past, education of pharmacists often failed to awaken a sense of concern and awareness of the health problems of the population. Students today have a unique need to express sincerity and are willing to work for a cause which appears worthy and meaningful to society. These students, however, must be presented the opportunity to encounter-with appropriate guidance-some of the glaring medical needs and problems of today's society. As far as pharmacy students are concerned, there is needed a wellbalanced combination of theoretical courses, interspersed with a variety of clinical experiences, which will sensitize these students to the needs of society and stimulate a desire to be of genuine service. Provision of this type of pharmacy education is based on the following broad goals1. To provide effective programs of
instruction and experience at the undergraduate, professional and graduate levels in humanistic, scientific and clinical areas to prepare students to meet the multifaceted needs of society. 2. To promote research programs of excellence in both basic and applied fields. Many of these research projects involve drug and health problems peculiar to an urban setting. 3. To achieve optimum interaction between the college of pharmacy and the community by providing educational services to the public in matters pertaining to drug use and abuse, and by offering consultation services to community pharmacies and health care institutions in regard to the provision of optimum pharmaceutical services to the public. As indicated in the first goal, at the undergraduate, professional and graduate levels, effective programs of Pharmaceutical education should include humanistic, scientific and clinical areas, including service aspects as well. To this end, students should receive courses in pathology, biopharmaceutics and in the social aspects of health care. In addition to these condition-
Sister Emmanuel, DC, is a member of the Daughters of Charity of St. Vincent de Paul and a registered pharmacist in New York, Connecticut, Florida, Virginia and Michigan. She is an assistant professor of clinical pharmacy at Wayne State University college of pharmacy and pharmacy consultant for Providence Hospital, Southfield, Michigan. Sister Emmanuel received her BS in pharmacy from St. John's University and her MS in pharmaceutical administration from Wayne State University. She is a m·ember of APhA, currently serving as a member of the Professional Affairs Committee, and is also a member of ASHP.
ing courses, students should be placed in situations where they have the opportunity to observe, and in some instances to assist conscientious practitioners who are attempting to bridge the gap between the reality and the availability of comprehensive pharmaceutical services. Pharmacy students, both undergraduate and graduate, need to be exposed to the many ramifications of pharmaceutical services that are characteristic of the seventies including the communication techniques involved in providing consultation services to all segments of the public. To thus reflect the health care needs of society in the educational programs of a college of pharmacy necessitates involvement on the part of faculty and students with the design and delivery of meaningful pharmaceutical services. This, in turn, involves face-to-face interaction of faculty and students with practicing pharmacists, other health care professionals and society itself. For years field work has been an accepted and essential part in the education of public health nurses and social workers who, through these type of experiences, were brought face-toface with people who needed their professional services. While there may be many pharmacists today who argue that the public is not interested in recetvmg consultation services from pharmacists, there are others who ardently believe that once the public experiences a sense of genuine concern on the part of pharmacists-a concern which can only be experienced by faceto-face communication-the public will just as eagerly seek and respect
the advice of the pharmacist as it now does other members of the health care team.
Community Pharmacy Pilot Program The community pharmacy clinical experiences offered to date in the pilot program at Wayne State University college of pharmacy have been at the graduate level. In September 1969, a group of seven advanced standing graduate students who were matriculating for a master of science degree participated in a pilot program referred to as "Research in Clinical Pharmacy." In this program each graduate student received clinical pharmacy experiences in both institutional and community pharmacy practice. As prerequisites, or co-requisites, the students involved were required to have courses in pathological states and processes, clinical pathology, clinical pharmacology, biopharmaceutics and biostatistics. The program development was based on the cooperation of four community hospitals, 14 community pharmacies, one county mental health clinic and more recently through the involvement of the college of pharmacy in the provision of services in a Model Cities Neighborhood program as shown in Table I (see below). Physicians and pharmacists cooperating in the program were contacted individually by the faculty coordinator of the program. The practicing physicians selected for participation in the program were primarily physicians involved in educational programs for medical interns and residents-physicians who had much to offer and who could be relied upon to involve the
TABLE I
Sites for Clinical Pharmacy Experiences Hospitals
g:~:~~~ ~~~~~~~~~~~: ~~;,a~~~~~~~).~t~::: :::::
::::::::: : : :::: ::::::::: ::::::: :: :: :: Pediatric (short-term, private, nonprofit) .... .... · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · Community pharmacies . ...... .... .. .. ...... · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · Model Cities Neighborhood program ................. · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · County mental health clinic ................................ · · · · · · · · · · · · · · · · · · · · · · · · · Total
Vol. NSll, No. 2, February 1971
i 1 1 1 1
20
49
TABLE II
Graduate Student Clinical Pharmacy Field Experiences Number of students involved. . . . . . . . . . . . . . . . . 7 Number of quarters per year. . . . . . . . . . . . . . . . . 3 Days per week for each student. . . . . . . . . . . . . . 1 Hours per quarter for each student..... . . . . . . . 85 Hours per three quarters for each student. . . . . . 256 (Community clinical pharmacy experiences 90 hours) (Hospital clinical pharmacy experiences 166 hours)
graduate pharmacy students in drugrelated discussions while participating in patient rounds. In the case of participating community pharmacies, onsite visits were made to each pharmacy to ascertain the type of experiences available and to provide a thorough explanation of the type of clinical experiences desired. The pilot program beginning in the fall of 1969 involved seven students for a total of three quarters (Table II, see above) . At the beginning of each
quarter an individualized schedule was presented to each student (Figure 1, see below). Each student spends one full day per week in obtaining clinical pharmacy field experiences and by the end of the program will accumulate 256 hours of experience, 90 hours of which . takes place in community pharmacies (Table II, see above). Of the 14 community pharmacies selected eight were apothecary-type pharmacies and six were of the gen-
FIGURE
eral type, including both independent and chain-type pharmacies (Table Ill, page 51). The 14 community pharmacies now serving as a base for graduate students' clinical pharmacy experiences were selected on the availability of either a unique service or a variety of services which would serve to broaden the students' clinical experiences-and on the willingness of the owner and pharmacists staffing the community pharmacy-to cooperate with the clinical pharmacy program. Pharmacy students participating in the pilot program are assigned an average of 90 hours (ranging 7 4-102 hours) of clinical pharmacy experiences in the various community pharmacies (Table IV, page 51). Community Pharmacy Experiences In community pharmacies as well as in hospitals the intent is to provide experiences which will not only assist
1
TO: Thomas Hunter, RPh FROM: Sister Emmanuel, Assistant Professor of Clinical Pharmacy SUBJECT: Schedule for Clinical Pharmacy Research-PHA 0895-Fall Quarter DATE: September 7, 1969 DAY OF EXPERIENCE: Thursday
Date
Time
Location of Experience
Type of Clinical Experience
Report To:
9-25-69
9 :OQ-10 :00 a.m. 10 :OQ-12 :00 noon 1 :3D-4:30p.m.
Detroit General Hospital Detroit General Hospital Tri Medico Pharmacy
Rheumatoid teaching session Rheumatology O.P. clinic Nursing home consultation
Brinkman, MD " " H. Gold, RPh
10-2-69
9 :OQ-10 :00 a.m. 10 :OQ-12 :00 noon 1 :3Q-4 :30 p.m.
Detroit General Hospital Detroit General Hospital Tri Medico Pharmacy
Rheumatoid teaching session Rheumatology O.P. clinic Nursing home consultation
Brinkman, MD H. Gold,
10-16-69
8 :OQ-10 :00 a.m. 11 :OQ-11 :30 a.m. 12 :OQ-1 :00 p.m. 2 :3Q-5 :00 p.m.
Providence Hospital Providence Hospital Providence Hospital Tri Medico Pharmacy
Internal medicine and cardiology rounds Necropsy review Tumor board case presentation Nursing home consultation
Berman, MD " " Pfeifer, MD H. Gold, RPh
10-23-69
8 :OQ-10:00 a.m. 11 :OQ-12 :00 noon 12 :OQ-1 :00 p.m. 2 :3Q-5 :00 p.m.
Providence Hospital Providence Hospital Providence Hospital Tri Medico Pharmacy
Internal medicine and cardiology rounds Necropsy review Tumor board case presentation Nursing home consultation
Berman, MD " " Pfeifer, MD H. Gold, RPh
10-30-69
8 :OQ-10 :00 a.m. 10:00-11 :30 a.m. 1 :3Q-4 :30 p.m.
Providence Hospital Providence Hospital Tri Medico Pharmacy
G.I. rounds Teaching rounds in medicine Nursing home consultation
Gelzayd, MD Zobl, MD H. Gold, RPh
11-6-69
8 :OQ-10 :00 a.m. 10 :OQ-11 :30 a.m. 1 :3Q-4 :30 p.m.
Providence Hospital Providence Hospital Nottingham Pharmacy
G.I. rounds Teaching rounds in medicine Rx and OTC consultation
Gelzayd, MD Zobl, MD M. Gowman, RPh
11-13-69
9 :OQ-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4 :30 p.m.
Nottingham Pharmacy Detroit General Hospital Detroit General Hospital
Rx and OTC consultation Dermatology rounds with junior medical students Cardiology lecture by residents
M. Gowman, RPh Rudner, MD Schatz, MD
11-20-69
8 :3Q-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4:30 p.m.
Cunningham's Pharmacy Detroit General Hospital Detroit General Hospital
Rx and OTC consultation Dermatology rounds with junior medical students Cardiology lecture by residents
A. Koorhan, RPh Rudner, MD Schatz, MD
* 12-4-69
10 :3Q-ll :30 a.m. 1 :3Q-4:30 p.m.
V.A. Hospital, Allen Park Cunningham's Pharmacy
Present dermatology lecture to resident staff Rx and OTC consultation
Duke, Resident MD A. Koorhan, RPh
12-11-69
8 :3Q-11 :30 a.m. 1 :OQ-2 :30 p.m. 3 :3Q-4 :30 p.m.
Cunningham's Pharmacy Detroit General Hospital Detroit General Hospital
Patient Rx and OTC consultation Dermatology rounds with medical students Cardiology lecture by residents
A. Koorhan, RPh Rudner, MD Schatz, MD
,
,,
~Ph
<~ Assi~nment-Contact Dr. Duke, Senior Medical Resident at Detroit General Hospital, for subjects to be included in preparing lecture on "PsychopharmacologiCal Agents Used in Dermatology." Outline to be reviewed with instructor prior to presenting lecture. Submit two copies of lecture outline in detail.
50
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
future practitioners to serve at their greatest potential, but those which will affect students in such a way that they more easily will acquire the intellectual and moral strengths to make correct value judgments in the provision of consultation services. To this end, students are assigned community pharmacy experiences wherein they will be provided the opportunity to · offer consultation services to individuals and to families in regard to pre"' scriptions, o-t-c medications, surgical supplies and appliances, and where they can assist in the development and use of patient profiles. Particular attention is given to developing concepts which encourage group practice and a family pharmacist type of service.
TABLE III
Pharmacies in Clinical Pharmacy Program Classified by Type of Service Provided Apothecary pharmacy (prescriptions, o-t-c's). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apothecary pharmacy primarily serving health care facilities. . . . . . . . . . . . . . . . . Apothecary pharmacy with diagnostic lab............. . . . . . . . . . . . . . . . . . . . . . General-type pharmacies (prescriptions, o-t-c's, surgical supplies, accessories and sundries) Independent type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chain type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total
Again this week I was able to mingle with the patients in front of the prescription counter. I have gained more confidence although at first, I must admit, I was somewhat in doubt as to whether I had anything to offer these people. I am now convinced that I have contributed something to their needs and can ascertain this by the surprised and appreciative comments made to me by patients. I learned that people are greatly in need of consultation. Most people haven't the faintest notion as to how important it is to take their medication or, in
5 1
14
TABLE IV
Hours of Community Clinical Pharmacy Experiences per Student Types of Pharmacies
Average Number Hours per Student/3 Quarters
Independent community pharmacy Chain pharmacy Pharmacy serving nursing homes Pharmacy with diagnostic laboratory Pharmacy with surgical supplies Pharmacy in medical building Community mental health clinic
8-12 12-16 14-18 12-16 12-16 12-16 4-8
General Type Pharmacies
The five independent type and one chain type pharmacies were selected from areas of the city which provided service to either low, average or highincome persons. In these pharmacies students received prescription orders ·from the patients and consulted with them both before and after the prescription orders were dispensed. Students, however, were not involved in the actual dispensing of the prescription orders. In the chain pharmacy, located in a disadvantaged area, students spent 12-16 hours becoming acquainted with the health problems of the poor as well as in gaining insight into the economic, social and psychological problems of the disadvantaged. The independent type . pharmacies provided students the opportunity to contrast various types and degrees of professional practice, to observe and personally experience the frustrations of providing patient-oriented services and, finally, to formulate methods of achieving clinical roles in community practice. Students' reactions to each experience were captured on a "Clinical Experience Report" (Figure 2, page 52) which was submitted to their clinical coordinator following each clinical pharmacy experience. Typical student comments included-
5 1 2
Total No. Hours 74-102
some instances, how dangerous some of the o-t-c preparations very likely could be to them. I learned that people are most appreciative of the time which I spent talking with them. I talked to numerous other patients, mostly about how to take their medications. Several people just wanted to talk and I found this interesting from the point of view that this is the exact way to build up respect and a professional acceptance from the people. This type of experience also helps one develop an all-around knowledge of the patient. I found this experience fairly rewarding.
Most students found it difficult, at first, to relate to patients, especially those from disadvantaged areas, and had to be encouraged and supported in gaining this type of experience. Without a doubt, however, this type of experience served to sensitize the students to the specific problems and needs of the disadvantaged and assisted the students in developing an attitude of sincere concern and respect which often made it necessary that the students attempt to overcome themselves in order to be of service.
Nursing Homes During their orientation to nursing homes students consulted with nursing home ~dministrators, made rounds on the nursing units where they reviewed patient records and answered drug-related questions from physicians and nurses. The community pharmacist
participating in this area assigned each student four out of the 18 nursing homes he was servicing in which to present a lecture on drugs used in specific clinical situations. Each student also was responsible for preparing two clinically oriented pharmacy bulletins for distribution to the nursing homes involved in the program. Additionally, working with an on-site pharmacy which was participating in the program, several stude~ts spe~t a considerable amount of their own time in providing extra consultation services which involved the setting up of a patient drug profile system and an extensive drug incompatibility file in one of the 200-bed nursing homes. Students reacted positively to their experience of providing lectures in th~ nursing homes although they found It difficult to adjust the level of their lectures to an assorted audience of nurses, practical nurses and aides. By means of patients' chart reviews ~nd through conversation with the nursmg staff and community pharmacists servicing these nursing homes, students gained insight as to the special drug problems of nursing home patients as expressed by several of the following comments/ am becoming more and more convinced that the pharmacist should play an important role in the management of drug therapy in the nursing home. Since the attending physicians make rounds less frequently than in a hospital, there is a greater need here for a medication consultant. Vol. NSll, No. 2, February 1971
51
FIGURE
2
Clinical Experience Report for PHA 0895-Research in Clinical Pharmacy STUDENT Thomas Hunter, RPh DATE OF EXPERIENCE 12-11-69' TIME LOCATION Cunningham's ~cy (Hospital or
8:\30-1'1.:30 a.m.
~harmacy)
TYPE OF EXPERIENCE Patient Consultatiop, on 'Rx· $<1 OTC Items (Patient Rounds, D.P.D., Consultation to /fol,l:I.," etc
PHYSICIAN OR PHARMACIST Mr. Koohan 1 ,RP:h a ' SUPERVISING E:x;PElUENCE . . 4 DIRECTIONS: Submit two typed clinical experiepce relilort forms sff)Peao of time spent in each clinical, experience. 1. Describe briefly what was provided through thfS· ~lini This was a unique experience as I was given the
tion order from ·the patient and returning the with advice on how to take the medication, p,re 2. What did you learn? · r learned that people really need this typ hav~n't the faintest concept of the >:il,nport supposed to. Patients don't realize that urine, or that some drugs should be taken. 3. What contribution did you 711ake concl!tfling I discussed the above type of. information appreciative. I demonstrat~.d to one.w,patient mistometer. I explained to• another ' patient ~, antacid along with aspirin. One 'patient request~d ad>fice op tion and I made specific r~commend~tions. ,NO'w that I am operation I .am beginning to feel more com£ortaple. ' 6 4. Comments: .. ,, I definitely feel that such a role is necessary fo~3lle elin,icallY, ori tainly appears to be most valuable to those patien't$ ar.~
who
This experience provided me an opportunity to orient myself to the requirements imposed upon the program of pharmaceutical services in nursing homes. This experience afforded me an opportunity to review patient charts and to be available for consultation. This type of experience is worthwhile in that it prepares one, or, at least gives the clinical pharmacist experience in presenting lectures thereby enhancing his background as an educator. In situations of this type the liaison between the nursing home nurse and the consultant pharmacist is strengthened allowing a somewhat greater degree of freedom in the exchange of knowledge concerning patient care and drug therapy. This week I spent some additional time on the nursing unit to evaluate the type of medication records which the nursing home keeps. This was done for the purpose of making recommendations for the patient profile which the pharmacy has definitely decided to provide.
Diagnostic Lab Both of the pharmacies with diagnostic labs participating in the pilot program were managed by registered pharmacists. Students, therefore, were not only provided a unique opportunity to become familiar with the types and significance of tests used in diagnosing a variety of clinical conditions, but also, during the three to four afternoons spent in this area, had the opportunity to correlate prescription 52
orders with diagnostic test orders which were presented by patients with specific medical problems. Students found the opportunity to research and discuss drugs which interfere with particular diagnostic tests both challenging and rewarding. Several students, however, were of the opinion that the experience could have been more beneficial if patients with clinical problems could be followed from the physi~ian's office through the diagnostic testing procedure to the time of final diagnosis. Pharmacists practicing in these prescription and diagnostic labonitories were most responsive to student discussions on drug-drug and drugdiagnostic test incompatibilities ahd together with the students worked out systems of reporting incompatibilities to physicians. Student response to this experience is indicated by the following commentsDuring this experience the pharmacist in charge and I discussed a reporting system that could be used to notify physicians of medications which may alter laboratory results. A [so, we discussed the information which would have to be on hand in order to detect these incompatibilites. Discussed the need to correlate laboratory test results with patient drug regimes. Noted how difficult it is to represent to a physician that an abnormal test value may be due to drugs. Very interesting. Might be somewhat more beneficial, however, if we could
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
take a patient with some pathological problem from the initial interview with the physician, through the laboratory tests to the final diagnosis. I would find it interesting if there was a laboratory-oriented course in which we discussed the details involving the~e laboratory tests, the principles behind them, the inherent problems with them, what factors affect them, etc . ... and also actually perform these tests ourselves so that we may become more intimately acquainted with these tests. I feel I could also use more detailed pathology concerning the individual laboratory tests.
Surgical and Health-Related Items This clinical experience in a pharmacy specializing in surgical and health-related items provided the opportunity to become familiarized with a large number of health and surgical supplies and accessories, to consult with patients on these items and to assist in the provision of home care services. For most students, this experience clarified the need for a pharmacist consultant service in this area. One student stated, "A drug profile should be established on patients using colostomy or ileostomy appliances in order to identify drugs which might induce specific problems in these patients." Most students reacted positivelyInteresting to see how a poorly defined system of health care exists for the post-hospital colostomy patient. Patients and pharmacists (since pharmacists are generally the first asked) need to know where to procure these items and how they should be used properly. During this experience I was privileged to observe about two hours of consultation with a recent colostomy patient who had an ostomy operation less than ten days ago. It was interesting to observe the rapport that was developing between the pharmacist and the patient. I became aware of the pharmacists reasons for selling and renting surgical supplies; that is, the pharmacist is attempting to fill the present gap between care of the patient in the hospital an.tj, follow-up care at home.
Medical
~uilding
Pharmacy
During this experience students spent their time observing and providing drug therapy consultation services in physicians' offices within the medical building. Appointments to consult with physicians in their offices were made in advance and on the afternoon of each assignment the student involved consulted with at least three to four physicians. Physicians practicing the same specialty, i.e. pediatricians, were, as far as possible, seiected for the same afternoon thus permitting students to prepare, dis-
and I observed four patients interviewed. I observed over 15 patients who were mostly children from one month to 13 years of age. For each child, I was briefed on the history and then introduced to the treatment prescribed. I was also given an explanation for the rationale for prescribing certain medications for specific age groups.
Goals to Be Derived Graduate pharmacy student discusses current drug therapy with a group of nursing home personnel. Arrangements for this experience were set up through a community pharmacy serving the nursing home.
In the Wayne State University college of pharmacy program, community pharmacists located in medical buildings arrange for pharmacy students to consult with physicians practicing within the same building.
tribute and discuss handout material on drug incompatibilities, etc. which would be of particular interest to a given group of physician specialists. Observations in the physicians' offices provided insight as to typical symptoms of disease, methods of diagnosing and an opportunity to learn physicians' reasons for prescribing certain drugs in preference to others which the student might have learned were equally, or perhaps more, effective in certain situations. While physicians responded to the presence of the student as an observer, there was a much less positive response when students were given appointments to discuss drug therapy with physicians. In this latter role some physicians and their office personnel were inclined to react to the students in the same fashion as they would to representatives of drug manufacturing firms primarily because they had · no prior experience with pharmacists in this new role. This experience helped the students to realize that the pharmacy practitioner's role as a communicator of health care information with other health care practitioners ca11s for as much psychological finesse, if not more, than between a pharmacist and
a person who seeks advice regarding personal health care problems. Student comments bear out both physician and student reactions to the programBoth physicians thanked me for talking to them and asked me to call on them again. In each office I did not wait at all. I talked with one physician for ten minutes and another for one-half hour (clinical pharmacy, etc.). For this type of consultation the pharmacist must be relevant. I was not able to complete my talk as the physicians asked me many questions on other subjects. This week was not as successful as the first week. I did not have to wait long to see the physicians but found the physicians too busy. One physician admitted that drug interactions wer,e a problem and then dismissed me. A second physician agreed that something should be done and insisted that he was doing it. Consulted with three physicians. I discussed what drug interactions are, their significance, types of interactions and the role of the pharmacist. I then discussed some of the newer drug reactions. I was placed in the office of a physician who specialized in ophthalmology. We talked of his philosophy of drug use
What is to be achieved through the involvement of community pharmacies in the development of clinically oriented pharmacy students? The principal value of these experiences appears to be that they develop in the students empathy for people, a very important consideration, because this, in turn, urges students to seek out and participate in providing those services which offer a distinct contribution to society. In developing educational programs it is well to keep this goal in mind because all the clinical knowledge in the world is worthless to a pharmacist in direct contact with the public unless he first has an abiding concern for his fellow man. It is concern for others that impels man to action. In community pharmacy practice there exists perhaps more challenging opportunities than in a hospital to apply the principles of drug monitoring, to offer consultation services, to assist in the detection and prevention of adverse drug reactions and to educate the public to seek drug information from proper sources. Conclusion
For several reasons, as might be expected, students did not react as positively to clinically oriented community pharmacy experiences as those provided within a hospital environment. Both students and community pharmacists involved in the experiences were somewhat uncertain as to the objectives to be sought and the ultimate value which students were to receive from each experience. Undoubtedly, because all of the graduate students involved were hospital pharmacists, it was logical to expect less interest in community pharmacy aspects of clinical pharmacy practice. An informal discussion period held each quarter-during which students related their experiences and the instructor re-emphasized the objectives sought in each community experience -did not prove adequate. There appears to be a much greater need for more frequent discussion periods which not only would better prepare students for each experience but would permit the instructor to more effectively correlate the philosophy behind (continued on page 63) Vol. NSll, No. 2, February 1971
53
community, dedicated health professionals, and intensive participation and involvement of the residents being served. The Comprehensive Health Center provides an effective way to maximize the utilization of scarce dollar resources. The Neighborhood Health Center enables all individuals to be integrated into the mainstream of medical care. The center enables the under-utilized pharmacist to apply his training and knowledge, in addition to participating as a viable member of the health team. The health center also serves as a training facility in which individuals can be trained in such new roles as family ·health workers, medical assistants, pharmacy technicians and mental health aides. The center therefore will not only provide substantive jobs but also will provide upward job mobility for area residents. The various "help" programs thus become an effective tool in reducing and finally in eliminating one cause of poverty. The Neighborhood Health Center provides the setting whereby effective team relationships can be implemented between health professionals and individuals desiring services.
In conclusion, it can be stated that the Neighborhood Health Center concept has been accepted as a relatively efficient mechanism of delivering highquality comprehensive health services to those in need. The era of pharmacists remaining within the "four walls" of their pharmacies in order to be successful is now in the past. Today, pharmacists are rendering comprehensive pharmacy health service to patients and health professionals outside their traditional "four walls." This has contributed toward changing the professional role of pharmacists. At the present time and even more so in the future, pharmacists will become increasingly oriented toward the health needs of the community. The "action pharmacists" have been given the opportunity to render complete pharmaceutical service to individuals who have thought of health care with low priority. Concurrently, all pharmacists must deliver quality complete pharmaceutical service to the rest of our society if the profession of pharmacy is to remain a viable member of the health team of the present and the health delivery system of the future. •
Community Pharmacy
In such well-balanced programs, pharmacy students would be given the opportunity to apply their knowledge in a fashion in keeping with the needs and demands of society. What the impact of the present program will have on pharmacy practitioners and the upgrading of pharmacy practice only time will tell. For the present, however, the effect on graduate students and pharmacy practitioners has-in a majority of casesbeen most rewarding. Much meaningful dialogue has taken place and a keen interest on the part of students and practitioners to apply principles of clinical pharmacy practice has been witnessed in many instances. •
(continued from page 53)
the development of the program. There is a need also to correlate clinical experiences more closely with scientific course work, including course work on public health and sociological courses, as well as scientific courses such as pharmacology and medicinals. Finally, participating community pharmacists should be brought more effectively into the planning and continuous redesign of field experience programs. Predicting the Future
What the future holds for pharmaceutical education is a challenging consideration. Through close association with other members of the patient care team in both hospital and community pharmacy practice there is evolving a greater respect among the professions based on a new awareness of each profession's problems, contributions and · needs. Hopefully, in time the pharmacy curriculum will be so adjusted that undergraduate students will spend at least the last six months of their formal education in a collegeformulated clerkship program. Ideally, this type of clerkship will be accepted by the boards of pharmacy in each state in place of the usual internship programs. In well-designed and controlled college of pharmacy clerkship programs, students would rotate between hospitals and community pharmacies to obtain clinical pharmacy and practical dispensing experiences.
References 1. Health Task Force of the Urban Coalition, Rx For Action, A report prepared by the Health Task Force of the Urban Coalition, Washington, D.C. (1969) 2. Novitch, Mark, Changing Patterns in the Delivery of Pharmaceutical Services as Viewed by a Physician, Summary repo·rt prepared by The University of California school of pharmacy from a presentation at the School of Pharmacy Faculty Conference (April 1-2, 1969) San Francisco, The University of California school of pharmacy (1969) 3. Cluff, L.E.; Seidl, L.G., and Thornton, G.F ., "Epidemiological Studies of Adverse Drug Reactions," Am. J. of Public Health, 55 (Aug. 1965) 4. Gardner, Vincent R., Changing Patterns in the Delivery of Pharmaceutical Services as Viewed by a Pharmacist, Summary teport prepared by The University of California school of pharmacy from a presentation at the School of Pharmacy Faculty Conference (April 1-2, 1969) San Francisco, The University of California school of pharmacy (1969)
Pharmacist Cites Team Effort The importance of a good pharmacist-
nursing relationship in the care of elderly patients cannot be overemphasized, says APhA member Peter Bruno (above), staff pharmacist at the Brookwood Convalescent Center in Des Plaines, Illinois. Also, the pharmacist is available at all times to consult with the physician concerning various drugs, drug incompatibility and drug interaction. Pharmacist Bruno is able to check with the physician, as needed, to confirm the dosage of a particular drug or the length of time which it is to be taken. Drugs prescribed by the physician have an automatic stop order after a specified period of time. If the drug is to be continued the physician must issue a new order. "It is gratifying to see the results of the physician-nurse-pharmacist team effort," Bruno said. "If, for example, a drug isn't doing the job it should be doing, the nurse calls it to my attention. I, in turn, notify the physician and he can change the drug or the dosage. This type of problem is prevalent in the antibiotics . . . what's good for one patient is not necessarily the :right drug for another." Since joining the staff at Brookwood, Bruno has ins1tituted several of the latest methods of drug control. One of these is the floor control system in which an account slip is pulled from a master form each time a drug is dispensed. This system is checked three times each day since the head nurses validate the orders at the end of each tour of duty. The system aids in narcotic control, helps in maintaining an accurate drug inventory and is a great friend of the patient since he or she is charged only for the drugs that are dispensed. The other method of drug control is the unit dose. The drugs come in a one-day supply or as a single dose, giving the pharmacist complete control of his drug stores. The drugs cannot lose their vitality and they cannot become contaminated since only those that are to be used immediately are available in the small, sealed container. Vol. NSll, No. 2, February 1971
63