Science and Profession Traditionally, pharmacy was confined to the distribution and dispensation of medications, but modern pharmacists have become recognized drug experts. The concept of pharmaceutical care promises to change pharmacy practice for the public’s benefit.
Pharmacy has always been primarily a retail practice. In the early days of the profession, physicians would often choose not to prepare medications for their patients, instead referring them to apothecaries, who would receive the prescriptions and then prepare and dispense them. A patient who was familiar with the symptoms of his or her ailment might choose to return to the apothecary to seek another course of this medication. Recognizing that many problems responded well to standardized medicinal formulas, many apothecary shops began to sell ready-made products to accommodate patients who chose to seek care from the pharmacist rather than the physician. A similar situation exists in modern times with over-the-counter medications, which are available without a prescription.
Until the 1970s, basic pharmaceutical practice changed very little. Physicians continued to devote themselves to the diagnosis and treatment of patients, and pharmacists continued to concentrate on dispensing pharmaceutical products. By this time, most of the collection and preparation (compounding) phases of the medication-developing process were being performed by the suddenly expanding pharmaceutical industry. Most medications arrived at the pharmacy in a ready-to-dispense form, such as a tablet, capsule, elixir, syrup, suppository, or ointment. This trend has progressed to the point that fewer than 1 percent of prescriptions require compounding by the pharmacist.
Most people have some understanding of pharmacy and pharmacists, usually through visits to the local drugstore. In this setting, pharmacists practice what is known as retail or community pharmacy. For many customers, it is unclear whether the pharmacist is a businessperson or a health-care professional; in fact, the answer is both. On one hand, a pharmacy often sells merchandise that many people associate with a variety store, such as pens, greeting cards, gift items, and beauty products. On the other hand, a pharmacy also has a license to sell something no variety store can: prescriptions, such as antibiotics for infections, pain medication for broken bones, or medication for high blood pressure to help prevent a stroke or heart attack.
Modern retail pharmacists operate and manage complex businesses. Pharmacists in this setting have additional challenges, such as personnel management, the organizational structure of the pharmacy, and the general focus of the business. Unrecognized activities may involve location analysis and selection, obtaining loans to purchase and operate the business, and store design. The pharmacist must evaluate computer systems for the purposes of dispensing medicine, controlling inventory, reordering stock, and interfacing with insurance companies for payment.
Not all retail pharmacy activity occurs in a community-based store. Many companies have founded large conglomerates called chain pharmacies. Occasionally, these chain stores may resemble independent community stores, but they still share common ownership. Most people are familiar with typical chain pharmacies within supermarkets and discount stores. Retail sales of prescription medicines have become increasingly available on the Internet as well.
Pharmacies in certain other practice sites, such as hospitals, are associated with the dispensation of many varied and highly complex medications. The medications dispensed in a hospital cannot be given to the patient for self-administration. Such medications include intramuscular or intravenous injections, implantable drug reservoirs, beads containing drugs, and medications requiring close observation of the patient. Hospital practice places a unique demand on the pharmacist to be a resource for drug information. Specialized pharmacists may become members of health-care teams where they provide a service to improve patient care rather than supplying a product.
During the 1980s, the insurance industry in the United States reformed payment methods for hospitals, trying to reduce the time that each patient remains in the hospital. The goal was to minimize cost by allowing the patient to recover at home. This policy reduced expensive payments to hospitals and shifted the expense to less costly home health care. Pharmacy’s ability to provide sophisticated medications in this setting allows the patient to stay at home and has created a growing segment of practice for some pharmacists.
Pharmacists are not limited to the practice types or settings mentioned above. Large pharmaceutical-manufacturing firms also employ many pharmacists in sales, marketing, management, and product development and manufacturing positions. Some pharmacists direct clinical research efforts, while others perform quality assurance or market research or hold positions in upper management.
One career track with tremendous significance to the profession is pharmacy education, a process that has seen many changes. Historically, European apothecaries used an apprenticeship system with no requirement for formal education; in contrast, modern pharmacists are well educated, often having more than 150 college-credit hours at graduation. After graduation, many pharmacy students will choose further study for an advanced degree. These degrees may focus on management (master of business administration, master of hospital pharmacy), academic work (master of science, doctor of philosophy), or postgraduate clinical studies (doctor of pharmacy). Traditionally, after completion of an advanced degree, most pharmacists join faculties at colleges of pharmacy. Others are recruited by institutional and corporate employers who find that such advanced training provides employees with skills that are beneficial to company operations.
The pharmacy student must complete an extensive application process to gain entry into a college of pharmacy. In addition to good grades, applicants usually must score well on the Pharmacy College Admission Test (PCAT), although this test is not required by all schools. Generally, an applicant must have a minimum of sixty-five hours of prepharmacy education. In the United States, required courses include English composition, general and organic chemistry, general biology (or botany and zoology), college physics, college algebra and trigonometry, principles of accounting, American history, principles of economics, and electives in the humanities and behavioral or social sciences.
One emerging area of pharmacy practice is the provision of clinical services. Clinical pharmacists are high-level consultants and experts on drug therapy and related issues. Many conduct daily patient rounds with physicians and other health-care providers. These clinical specialists review medication orders for appropriateness, verify proper doses, inform nurses of special issues when giving the medication, recommend laboratory tests and other monitoring procedures, and assess the outcome of treatment with the physician.
Once, most clinical specialists were associated with general internal medicine services. Then the need for clinical pharmacy services in other areas became apparent. To serve these patients properly, pharmacists established specialty practices. Recognized specialty areas in pharmacy include pediatrics, geriatrics, nutrition, drug information, ambulatory care, critical care, family medicine, surgery, cardiology, oncology, nuclear medicine, mental health, and pharmacokinetics, a specialty unique to pharmacists. Pharmacokinetics is a branch of pharmacology that studies what happens to a medication when it enters the body. These practitioners help choose the best dose of a medication in order to optimize clinical outcomes.
The increasing demands for enhanced services and the growing complexity of the tasks required to provide clinical services resulted in a need for further training. Many pharmacy specialists undergo residency training to provide this additional proficiency. In the United States, the Board of Pharmacy Specialities established credentials to allow pharmacists to become board certified within many of these specialty areas. Nonspecialized residency training is available in general hospital pharmacy practice. The hospital is becoming a complicated practice site that requires unique knowledge; this type of training addresses the particular needs of pharmacists in hospital practice.
A lesser-known area of practice for pharmacists is clinical research. The pharmacist may serve as the principal investigator or as a research coordinator for another investigator. The research may address questions about drugs already on the market, evaluate new treatments, or gather information about drug-related problems. In the United States, clinical research usually serves to provide the background material required by the Food and Drug Administration for a pharmaceutical manufacturer to sell a new medication. Results of this research are published in medical and pharmacy journals so that interested professionals have easy access to this new information and can apply it to patient care.
Diagnostic and Treatment Techniques Pharmaceutical care involves four major functions: curing disease, eliminating or reducing a patient’s symptom complex, arresting or slowing a disease process, and preventing a disease or its symptom complex. A pharmacist works with other professionals to design, carry out, and monitor a therapeutic plan that will produce specific therapeutic outcomes for the patient. These activities involve three major functions: identifying potential and actual drug-related problems, preventing potential drug-related problems, and resolving actual drug-related problems. This concept was conceived in the late 1980s by the nationally noted pharmacy educators Charles D. Hepler and Linda H. Strand, who recognized that pharmaceutical care is applied on three distinct levels: primary (outpatient and community pharmacies), secondary (acute care hospitals, skilled nursing facilities, home health care, and specialized care programs, such as oncology and pain control), and tertiary (inpatient critical care and teaching medical centers). Each level of practice demands specialized services from the pharmacist.
The specifics of pharmaceutical care have been described by noted pharmacists William E. Smith and Katherine Benderev as the sum of all pharmaceutical services, both clinical and nonclinical, that are required and received by a patient. The provision of pharmaceutical care means that the pharmacist is responsible for a patient’s achievement of the desired clinical outcome secondary to the use of medications. Inherent in this idea are the basic functions of the pharmacist common to all levels of care: developing and using a patient's medication profile; interpreting, questioning, clarifying, verifying, and validating all drug-related orders; providing a safe and efficient drug-dispensing system; monitoring drug therapies for safety, efficacy, and desired clinical outcome; screening for drug allergies, drug interactions, and concomitant drug use; detecting and reporting drug allergies and adverse reactions; recommending initial or alternative drug therapies; responding to drug information requests from physicians, nurses, and patients; teaching health-care providers and patients about drug use; obtaining medication histories by interviewing patients; assisting in the selection of the drugs of choice and dosage forms; conducting drug-use evaluations in order to gauge the appropriateness of drug use and the achievement of desired therapeutic outcomes; and applying pharmaceutical principles for selected drug therapies.
Pharmacy practice in a retail setting primarily stresses filling prescriptions, but many activities behind the scenes also help the patient. In addition to buying safe and reasonably priced products, the pharmacist must maintain a patient profile, which includes data about the patient's allergies, other medications, and other relevant information. The pharmacist uses the system to screen for drug interactions, to avoid potential allergic reactions, and to ensure that the patient receives proper doses of the medication.
Traditionally, patient education by pharmacists has consisted of a brief discussion augmented by precaution labels on prescription bottles. Pharmacists and other health-care professionals have since recognized the importance of more thorough patient education in achieving optimal results using medications. Methods include one-on-one counseling, audiovisual programs, preprinted or computer-generated handouts, and other specific information sources. Some retail pharmacists use their computer systems to send refill reminders, allowing pharmacists to assist physicians in their efforts to ensure that people with chronic problems are treated adequately. Hospital-based pharmacists may implement detailed discharge counseling for patients returning home in order to review treatment plans or answer questions about medications unfamiliar to the patient.
Many pharmacists perform a very valuable service in nursing homes and long-term care facilities by evaluating patients’ medication regimens for problems. Elderly patients often use six or more medications, making them more prone to dangerous drug interactions. They may also have many illnesses, making them more sensitive to the adverse effects of medications. Pharmacists assess whether chronic conditions are being controlled, whether medications are being stored and dispensed properly, and whether efforts to ensure the patient’s safety are adequate. The latter activity may include recommendations to stop the use of a medication because of side effects, drug interactions, or toxicity. Also, the pharmacist may recommend laboratory tests to monitor drug therapy.
One area where pharmacy practice is expanding is hospital practice. In the United States in the 1960s, the pharmaceutical-manufacturing process began to see radical growth, with both the numbers and the complexity of medications increasing steadily. Hospitalized patients place unique demands on pharmacists for specialized services. These pharmacists maintain their control and responsibility for dispensing medication, yet their role has extended into being part of the drug decision-making process. A simple example is a change in the traditional role of controlling medication inventory. The hospital pharmacist will establish and use a formulary, a list of medications approved for use in the hospital. Formularies control medication costs by preventing the purchase of unneeded products and placing restrictions on the use of expensive or dangerous medications. The pharmacist helps make complex decisions, such as determining the proper doses of highly toxic medications. Since hospitalized patients are very ill, watching for potential allergic reactions and side effects is very important. For cases in which treatment decisions are unclear, the pharmacist may aid the physician in selecting a treatment.
Often, hospitalized patients require special methods for the administration of medication. Pharmacists need to be knowledgeable about intramuscular and intravenous routes of administration. Intravenous medications may require complex mixing and preparation. These products must remain sterile, with no bacteria present, and may have special storage or handling requirements. Frequently, intravenous medication is given over a fixed amount of time; therefore, the pharmacist must be familiar with the infusion pumps that regulate the amount of solution dispensed over a given period. Many medications also require specialized tubing called catheters for administration. The pharmacist plays a central role in addressing any special needs of patients requiring complex medications.
All these activities require the pharmacist to work closely with other professionals in the hospital. Frequently, the pharmacist will work with nurses to ensure proper administration and timing of doses or to monitor the patient for side effects. Laboratory personnel need to understand that medications may affect certain laboratory tests. In addition, laboratory technicians may draw blood from the patient to check the concentrations of many types of medication. Proper timing of the sample collection is very important when considering making changes to the patient’s drug therapy.
Perspective and Prospects Pharmacy is a unique profession whose origins can be traced to the thirteenth century, when the Holy Roman emperor Frederick II issued an edict to separate the professions of pharmacy and medicine. Pharmacy became responsible for the preparation and dispensation of medications, and medicine became responsible for the diagnosis and treatment of the patient.
No professional practice is without change. Pharmacy practice evolved from the gathering, extraction, and preparation role of the apothecary to the contemporary role of medication distribution. Now, with the complexity of drug therapies increasing rapidly as new medications enter the market, physicians are becoming increasingly dependent on pharmacists to keep them informed of new developments, and pharmacists have become more active in dealing with patients and their physicians. Pharmaceutical care is a natural extension of this evolution, in which the pharmacist’s role becomes more patient centered rather than focusing on a product. The tenets of pharmaceutical care promise to become deeply ingrained in the practice of pharmacy, replacing the dated idea that a pharmacist's only role is to dispense medications.
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