Henri R. Manasse, Jr., Ph.D., Sc.D.
Standing high above the departure pier and gripping the guard rail on the ship’s upper deck, the eight-year-old boy felt the adventure and fear of the moment. Initially it was saying good-bye to family, friends, and the homeland, but later it would be sailing the North Atlantic and arriving in Hoboken, New Jersey, at the Holland-America Line’s disembarkation pier. He did not have a good sense of the encompassing nature and implications of it all. Little did he know that the North Atlantic is not a nice sea to sail in the middle of March, nor did he comprehend that a different language, culture, and set of social practices would face him. He did not fully appreciate that the decision by his parents to pick up and leave, with four boys under the age of nine in tow, was predicated in long hours of thoughtful and oftentimes emotional debate and analysis. He had no way of knowing how the ideals of his mother and father drove the decision to immigrate to the United States. How was he to know how these idealists were planning to translate their ideals into action in the new land?
That boy was me 53 years ago. I continue to reflect on my parents’ decision to leave their home in the Netherlands and start life anew in the United States. Had it not been for their ideals and their willingness to act on idealistic notions, I would not be standing before you today. I am especially grateful to my mother and my father for the decision that they made.
Indeed, coming to the United States in the manner that my family did during the post-World War II era, has given me much pause for reflection over the past decades. These reflections—namely that our world and our profession require a hearty dose of idealism and a commitment to nurturing idealists—have been distilled to serve as the focus of my lecture tonight.
Utopia
I would like to begin our discussion of idealism and idealists by recalling the work of Sir Thomas More, the 16th-century cleric and political antagonist of King Henry VIII. His essay of the same name introduced the word “utopia” into the English vocabulary. He envisioned a nonexistent place that had a perfect economic, social, and political system. More’s thinking served to capture a vision of how a society might become more perfect through careful consideration of specific ideals relating to economics, social structure, and political processes. He was no doubt influenced by the early Greco- Roman thinkers on this very subject. But more than likely, his work was also stimulated by his observations of England’s social and political evolution. More wished to stimulate a rethinking of the social order.
The word utopia has come to be used as a term of idealism and as a term of derision. But either way, utopia signifies an ideal that is being given voice by an idealist. It is probably not a stretch to conclude that America’s Founding Fathers, in writing the Declaration of Independence, were contemplating a utopia that would be far different from their experience in the “old world” and the new colonies. No doubt, our Founding Fathers had a good knowledge of More’s ideal.
Emile
In the 17th century, the French philosopher and educational theorist Jean Jacques Rousseau wrote Emile. Describing how Emile should be brought up through a nurturing process of mentoring in life lessons, Rousseau constructed an ideal that became the underpinning of modern educational psychology. In effect, he examined the worldview of child development as it existed in 17th century Europe and, through critical analysis, used the story of Emile to establish an ideal for raising and educating children.
Rousseau’s work served to stimulate further thinking and application by educational theorists and behavioralists throughout the 18th and 19th centuries in Europe and the United States. His ideals were incorporated into the theoretical and pragmatic models of early childhood education, which served to stimulate a rethinking of how and when children learn.
Johann Pestalozzi, the Swiss educational reformer, believed that teaching methods should conform to the natural order of child development and be adjusted as the child matures and expresses his or her individuality. He went so far as to suggest that teacher training should consist of a broad liberal education followed by research and professional training. The latter ideal has been largely adapted in contemporary European and American education, especially at the graduate level.
Pestalozzi’s ideals were later transferred to the seminal works of Jean Piaget. Piaget reinforced, through his own research and theoretical work, the phases of child development. He suggested that children naturally learn specific skills as they become aware of the importance of their knowing these skills. Piagetian psychology continues to be an important touch point for curricular development and child rearing.
What is utopia for hospital and health-system pharmacy? What is our vision for the ideal relationship between pharmacists and other health professionals, between pharmacists and patients? Unless we articulate that ideal and continuously refine it, we risk becoming stuck in the stereotypical rut that has and continues to shackle pharmacy.
Pharmacy idealists
Albert Prescott had an ideal to move pharmacy education out of an apprenticeship and “night school” model and bring it into laboratory-based university education. Much to the chagrin of the profession (he lost his credentials as a delegate for the American Pharmaceutical Association), he established the first university-based pharmacy curriculum in the United States after the Civil War at the University of Michigan. Included in Prescott’s ideal for the professional education of pharmacists were his notions of a science-based curriculum that was grounded in experimental work and the liberalization of the mind in a comprehensive university. These were heady thoughts for a profession that was grounded in a “look and see” model of vocational training!
Early thinking about a clinical role for the pharmacist began in the 1940s. Inspired by the revolution in drug development that came as a consequence of an expanding pharmaceutical industry and university-based research laboratories, pharmacy idealists, such as W. W. Charters and George L. Webster, inspired thinking about the need to have a well-educated and knowledgeable interface between the prescriber and the patient: namely, the pharmacist. These notions are inferred in The General Report of the Pharmaceutical Survey. This report served as the grounding ideal for the six-year doctor of pharmacy degree program. That recommendation was made in 1948!
Harvey A. K. Whitney was an outspoken idealist for hospital pharmacy and its future in the 1930s. In a recollection of some of Mr. Whitney’s ideals, Dr. Warren McConnell, in an oral history interview in 1995, noted that Whitney desired hospital pharmacists to become knowledgeable in the language of medicine and work side by side with physicians in ensuring safe and effective drug therapy. He required his interns to observe autopsies and read medical textbooks.
In the early 1950s, others advocated that a structured, postgraduate experience should be constructed for pharmacists wishing to practice at a higher level of competence and experience. Several thinkers cited the ideal that hospital pharmacy in particular would greatly advance if its practitioners completed such a program. This ideal served to develop residency programs and to have them accredited by the American Society of Health-System Pharmacists in order to ensure their quality and linkage to desired pharmacy services.
A reading of each of the previous Harvey A. K. Whitney Lectures reveals that the awardees were idealists with significant ideals for practice, education, and science in hospital and health-system pharmacy. Many of the ideals expressed in these lectures have been adopted and put into practice. But like most ideals, some will take many more years to take root and expand into reality. We must therefore continue to read and reread the works of our visionaries and carefully reflect on the philosophies that undergirded their visions. And if we adapt our own thinking to these philosophical premises, we have a duty to find ways to advocate for and implement their visions.
The future of our profession and its practice will face the normal challenges of change, fueled by social, economic, and cultural evolution and the development of new science and technologies. We are forever a profession at a crossroads, and that is how it should be. While there are many issues and challenges facing us at the emerging crossroads, three areas are deeply in need of ideals and idealists: (1) the competence and quality of our work force, (2) genomics, pharmacogenomics, and the other “-omics,” and (3) global connections in a flat world. Each of these areas is garnering much discussion in both professional and lay circles; however, there is plenty of room in each of these areas for ideals to be formed and for idealists to sow the seeds of a directed future.
Competence and quality of our work force
Our nation is undergoing a dramatic self-examination of the quality, safety, efficiency, and cost-effectiveness of our health care services system. Medication use and medicationrelated misadventures have come under closer scrutiny as specific measures, safety goals, standards, and “never-events” lists are created. However, as we in health-system practice know, the complexity of drug misadventures will not be easily remedied. We need a broader and deeper social and professional vision regarding appropriate drug therapy and its concomitant policy and implementation requirements.
At the root of this vision must be thoughtful contemplation about the quality and competence of our work force. While we have made significant gains through the expansion and revision of the curricula in our schools and colleges of pharmacy, we still need to do some deep thinking about the level and scope of competence required of our practitioners in hospitals and health systems. Equally, we need to contemplate our longterm vision with regard to postgraduate residency requirements, credentialing, licensure for advanced scopes of practice and how to retain and develop our current cadre of pharmacists. Very important for our vision is a need to resolve our profession’s “dirty little secret”—the lack of national consensus and action on the education, training, certification, and regulatory oversight of the pharmacy technician component of our workforce.
Our vision must also be directed to the quantity and quality of faculty that will be required in this time of unbridled expansion of the pharmacy education enterprise. We must also direct our vision toward ensuring that our nation has the capacity to accommodate an ever-growing student body for quality experiential education, especially the depth and breadth of clinical rotations in hospitals and health systems. And we need to give careful thought to the numbers of qualified leaders and the skills that will be required to lead our academic institutions during this time of rapid expansion and critical shortages of faculty. Our vision must ensure that the gains made in the past quarter century in successfully implementing a clinically and scientifically robust curriculum are absolutely not compromised.
In hospitals and health systems, the effective deployment of our work force should be steered by well-guided ideals. From the application of automation to appropriate utilization of pharmacy technicians to collaborative practice with our colleagues in medicine and nursing, our visionaries must engage us in futures thinking and doing. We should perhaps more forcefully and comprehensively define our desired future in hospital and health-system pharmacy practice and then, in our respective spheres of influence, ensure that our vision is realized.
In effectively developing a competent and qualified work force for tomorrow, we must today collectively ask ourselves where we are going. Secondly, we must question if our path is leading us in the right direction. Ultimately, each of us in our respective spheres of influence must strive to achieve a superior level of practice in providing quality medication therapy management and patient care. ASHP’s Long-Range Vision for the Pharmacy Work Force in Hospitals and Health Systems and the Future Vision of Pharmacy Practice articulated by the Joint Commission of Pharmacy Practitioners should be forceful guides.
Genomics, pharmacogenomics, and the other “-omics”
The identification of the genetic code in the double helix of DNA and the eventual unraveling of the human genome serve as the basis for the new scientific revolution in therapeutics and diagnostics. The visions of Watson and Crick in the 1950s and the leaders of several scientific groups around the world eventually led to the Human Genome Project at the National Institutes of Health and laboratories throughout the world. Their visions are now being realized in the fields being referred to as genomics, pharmacogenomics, proteomics, and other terms using the suffix “-omics.” Personalizing therapeutics based on genetic characteristics and predictions is now being seriously contemplated, and their clinical realities are being demonstrated in oncology, neurology and psychiatry, hematology, and anesthesiology. More and more drugs and their actions are being characterized from these perspectives. Moreover, gene therapy continues to be investigated and developed. The vision of being able to thwart or otherwise mitigate or even prevent certain pathologies is being realized in the laboratory and the clinical setting from a genetic perspective. The U.S. Food and Drug Administration and regulatory bodies around the world are struggling with their present authority as these new applications push the envelope of current laws and regulations. Reconsideration of what should be included in labeling is a serious contemporary agenda issue among the world’s drug, biologicals, and food regulators.
However, we need a vision for the role of the pharmacist in this exciting frontier of basic science, clinical medicine, and drug regulation. Some early pioneers in our profession are making their way forward. The American Journal of Health-System Pharmacy has begun to publish scientific investigations on this subject. Conferences are being organized around this theme. There is not yet clarity in our profession as to how pharmacy should be engaged. We need ideals and a vision about this.
We must also have a vision for the ethical and moral dimensions of these new scientific endeavors and their applications. As I have noted in previously published work, there is a well-established basis for legitimate concern about human experimentation in genetic therapies. What is our vision for ethical principles that should guide our work in this brave new world? How should our work in the genetic sciences be overseen? To whom are we ultimately accountable? How are patients to be engaged in dually monitoring and applying new discoveries? What should we absolutely not be doing? These are but a sampling of the questions that need to be answered.
In this arena of professional and civic debate, we must have a liberally educated pharmacist. Our profession will find it difficult to address these ethical issues from a purely scientific foundation, which is what we have in contemporary pharmacy education. Deeper humanistic and spiritual dimensions than provided by pharmacy education alone are needed to address these aspects of the genetic revolution. Maybe there is hope in the fact that more students who enter pharmacy school today already hold a degree in another field. But do the admission committees of schools of pharmacy give more priority to applicants who have a science degree than those who have a degree in the liberal arts?
Global connections
Thomas Friedman’s book The World is Flat: A Brief History of the Twenty-First Century has raised up a vision for a world that is fully globally connected. We have all seen or experienced the effects of globalization: accessing products from many countries with whom the United States has trade agreements, customer service agents who are based in countries outside of the United States, the provision of certain medical specialty services (e.g., interpretation of radiographic images by physicians who are doing their reviews outside of the American borders, more of our patients going to foreign countries to seek required or elective surgical services at a lower price than that offered in the United States). Our world is indeed becoming more flat through the Internet—faster, wider, and cheaper airline routes (e.g., flying from Washington, D.C., to Beijing in 14 hours); higher dependence on foreign workers; and a host of other factors.
It is easy for us Americans to be isolated in the flat world. We have a strong, individualistic self-concept as a nation: there is little we cannot do on our own. But we do so at our peril. This is true for the profession of pharmacy as well. The recently concluded Pharmaceutical Sciences World Congress demonstrated the global connections in science and technology: multinational groups of researchers working on similar issues and sharing findings. The upcoming 67th International Congress of the International Pharmaceutical Federation (FIP), to be held this coming August in Beijing, has as its theme “From Anecdote to Evidence: Pharmacists Helping Patients Make the Best Use of Medicines.” Next year’s conference, to be held in Basel, Switzerland, will have as its theme, “Reengineering Pharmacy Practice in a Changing World.” Do these themes sound familiar? They reflect the global concerns surrounding rational drug therapy, the quality of the drug supply, the responsiveness to patient needs around drug information, and the structuring of pharmacy practice to meet new governmental and social demands. As a result, our profession is becoming more globally connected. And we are coming to need each other as we position our profession for the future. With the rapid pace of global change affecting our profession daily, interconnections with our global counterparts is vital. We must begin to work together to tackle these changes and develop universal standards to improve the quality of care and safety we provide our patients. ASHP’s 2015 Health-System Pharmacy Initiative is one opportunity Americans have in leading these efforts. Our colleagues at the Canadian Society of Hospital Pharmacists have largely adopted ASHP’s 2015 Initiative.
It will also do us well to monitor the developments in the National Health Service (NHS) of the United Kingdom. With Scotland taking the lead, pharmacists are being granted the right to prescribe medicines. This initiative is being stimulated by issues of access, cost, and patient demand. It also reflects a desire to have pharmacy practitioners more integrated into the NHS as health care providers. The health care services system of Australia is pursuing similar objectives and is reimbursing pharmacists for drug-use review. In this process, pharmacists must send reports of their findings to the prescribing physicians. Substantial reform of pharmacy practice and pharmacy education is occurring in the Pacific Rim countries. Thailand, Japan, South Korea, Taiwan, and Singapore are each reexamining the role of pharmacists in their respective countries and reforming the pharmacy curriculum and the nature and scope of practice. But none of this is easy. It requires mutual support and encouragement between academics and practitioners in our global pharmacy community.
Fundamentally, the economic and social cost of inappropriate use of medicines has become a global issue. Moreover, the more effective use of the pharmacist work force is being increasingly examined by national governments as well as the World Health Organization (WHO). FIP is advocating strongly with the WHO on a variety of fronts, including work force issues, public health initiatives that require pharmacist participation, and ensuring the integrity of the drug supply.
A global vision for hospital pharmacy practice will be the focus of a 2008 invitational conference. Hospital pharmacy leaders from around the world, inclusive of those from developing, transitional, and developed countries, will be asked to create a consensus vision for practice in hospitals. That articulated vision will then serve as the agenda for advocacy and implementation around the world. The world is indeed flat. It would serve our profession well to include a vision of global pharmacy in our contemplation of the future.
In all of this globalization, we need ideals and idealists. Just as the Schuman Declaration in 1950 expressed an ideal for a united Europe, which provided the basis of moving toward a European Union, we need ideals at the root of what we would like our profession to be from a global perspective. We can no longer be seen as “drug sellers.” We must construct an ideal around the pharmacist’s real and present engagement in issues of global health and rational therapeutics.
Ensuring the nurturing of ideals and idealists
Our profession’s social imperative is clear: helping patients make the best use of medicines. It is perhaps not as succinctly stated in the legislative declarations of our state practice acts, the missions of our hospital and health-system pharmacy departments, and the everyday working principles of our practitioners. But it all boils down to ensuring the rational, safe, effective, and efficient use of the pharmaceutical armamentarium: the drugs, biologicals, vaccines, and diagnostic agents used by our patients. This is becoming an increasingly complex and daunting task.
Chemical and biological therapeutics will become even more complex. And so will the diagnostic markers that will be used to ensure desired therapeutic outcomes. The scientific revolution in genetics, the expansion of globalization, and our work force challenges will fuel that complexity. Other factors can assuredly be added to this mix, but suffice it to say for now that we better formulate a vision for our future in what Aldous Huxley called “the brave new world.”
Our times and their challenges call for us to nurture idealists, who will generate the ideals so desperately needed by our profession as it navigates the future’s turbulent seas. Who are these idealists, and where will they come from? Who will guide them and sustain them? And most importantly, who will listen and pave the way for them so that their ideals will find fertile fields?
Nurturing does not happen naturally or automatically. Directed efforts have to be applied. You and you and you have to be involved. We have to identify and nurture the dreamers among us. And those with a more pragmatic bent have to become translators of the ideals, translating the language of the dreamers into practical applications. As Val Cardinale recently noted, “The next 25 years hold promise of more clinical involvement and collaboration—and more respect for pharmacists.”
As always, we will need to continuously earn that respect. In every opportunity, we must strive to dispel the stereotypes of pharmacists within the health care community. Our actions must speak louder than our words, for to whom much is given, much is required. As seasoned practitioners in the profession of pharmacy, we must strive to pave the way for our future idealists. Therefore, I challenge each of you today, if you are not already, to start mentoring to two or three young practitioners.
The late Senator Paul Simon published a book titled We Can Do Better. While he focused on our political sector through letters to President Clinton, his message is applicable here: We have the collective intellectual strength and prowess to do better. That premise is equally true in our profession: We can do better! But doing better requires an underlying vision. The admonition of President Abraham Lincoln is applicable here: “I do the very best I know how—the very best I can; and I mean to keep on doing so until the end.”
As we contemplate these thoughts, let us also honor those who have been and continue to be our idealists—those who have done their best and those who have spoken to us through their words and deeds. We equally honor the ideals that have given us the basis of a way forward. Now it is our responsibility to call for and nurture a new cadre of idealists. We will welcome their voice and their visions. And we will sustain their dreams.
Acknowledgments
The late Walt Disney noted: It seems to me shallow and arrogant for any man in these times to claim he is completely self-made, that he owes all his success to his own unaided efforts. Many hands and hearts and minds generally contribute to anyone’s notable achievements.
And so it is with me. The nurturing of my parents; the camaraderie of my brothers and brothers-and sisters-in-law and their respective families; my small group of very personal and close friends and colleagues; the university faculty members with whom I have worked in Illinois, Minnesota, and Iowa; and the superb staff and tireless volunteer officers and board members of ASHP with whom I have had the privilege to work; have all contributed their immense gifts to any successes that I may have achieved.
But most of all, I want to pay tribute to my wife of 38 years, Arlynn Marie, and my children and their spouses: Bryan and Lauren and Sheralynn and Jeff. They have endured my being away from home, my periodic having to “work on something,” and joining me in many “boring” pharmacy events. Arlynn has been the “rock” of my life and has helped me to appreciate the joys of family, the beauty of nature, and the necessity of nourishing the spirit. Thank you, my love!
Editorial and content suggestions for this presentation were provided by my colleagues at ASHP. I extend my appreciation to William Zellmer, Charles Myers, Richard Talley, Stephen Allen, and Tyffani Wingfield for their review of my early thoughts and drafts. Their collective assistance was invaluable.
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Any references cited in this lecture are available in the PDF version.
Originally published in Am J Health-Syst Pharm. 2007; 64: 1685-92.
© 2007, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.