Where Do We Go from Here?
Thank you Mr. Macy, distinguished guests, fellow pharmacists, and friends. This is indeed a momentous occasion for me. I suppose that more nice things have been said about me in the last 30 minutes than in all the rest of my life put together. The praise has been overgenerous but, even after discounting, is music to my ears. It is very pleasant to receive such compliments, especially in the presence of one’s wife and boss. However, both of them know me so well, they are not likely to believe all that has been said.
To be named the 1962 recipient of the Harvey A. K. Whitney Lecture Award brought me a signal honor, one which I accept with a sense of humility and deep appreciation.
I am aware that this honor is not purely a personal accomplishment but reflects the influence and assistance of a host of friends and colleagues who, since early childhood, have kept me moving along a well-defined pharmaceutical path. Of these many people, the only one I shall attempt to single out is my wife, Mary, who gave up a promising career in hospital pharmacy to become associated with me on a permanent basis. While she has not written my speeches as some of you here tonight have inferred, she has played the role of a most astute critic. More important, through her efficient management of our household and family affairs, I have been able to devote more than a reasonable share of my energies to a rewarding and satisfying career.
Along with the honor that goes to the Whitney Award recipient goes the sobering responsibility of presenting a lecture, the subject of which is left to the recipient. So tonight, fully aware that nothing is more subject to the “Law of Diminishing Returns” than an after-dinner speech, I would like to talk with you in much the same manner that we would talk if you stopped by the hospital or our home for a visit. After an exchange of pleasantries and perhaps a brief review of current problems, I suspect our conversation would turn to the question of: “Where do we go from here?”
We are all familiar with the rapid growth of hospital pharmacy during the last two decades. Only 10 years ago, Alex Berman, the pharmacy historian, writing in the decennial issue of The Bulletin, had this to say about the development of hospital pharmacy:
One of the most dramatic and significant developments in the whole range of American pharmaceutical history has been the sudden emergence in recent years of a nationally organized and vigorous body of hospital pharmacy practitioners. Founded in 1942 as the American Society of Hospital Pharmacists, an affiliate of the APhA, this organization has in a brief span of 10 years become a potent force in American pharmacy.
Yet progress in the decade just completed has been even more phenomenal than that described by Dr. Berman.
Fortunately, we have had more than our share of dedicated leaders like Harvey Whitney to see that hospital pharmacy obtained an enviable place within the profession and within hospitals. As a result, we have our own Minimum Standard for Pharmacies in Hospitals and the Minimum Standard for Pharmacy Internships in Hospitals. The growth of specialized courses in hospital pharmacy at the graduate and undergraduate levels has been stimulated in many colleges of pharmacy. We have our own literature. The American Journal of Hospital Pharmacy is second to no publication in the entire health field. The American Hospital Formulary Service, with its continuing flow of supplements, is another tangible contribution of the Society which stands on its own merit. The institutes on hospital pharmacy sponsored by the American and Catholic Hospital Associations have done much to improve standards of practice and to stimulate hospital pharmacists throughout the country to do a better job.
We have attracted a significant number of young people in hospital pharmacy. Preliminary results of the Audit of Pharmaceutical Service in Hospitals, as reported at our annual meeting last year, reveal that an unusually large percentage of the pharmacists practicing in hospitals today are young. One-third of all hospital pharmacists are less than 30, and over 50% are less than 40 years of age. However, the fact that more than 50% of all hospital pharmacists are under 40 years of age and have worked in hospitals for less than six years indicates that our specialty is not maturing as it should. Further, the fact that 40% of the chief pharmacists in the country are under 40 years of age and 33% have practiced in hospitals for less than six years is cause for concern.
Can hospital pharmacy as a specialty attain maturity when each year we experience a significant loss of leadership to other fields? We might ask ourselves why do so many hospital pharmacists of all ages leave to enter the community practice of pharmacy, to become hospital administrators, to join the pharmaceutical industry, to enter graduate programs leading to other fields, or to study medicine.
In editorializing on hospital pharmacy manpower needs, Don Francke points out that the Audit results show the replacement factor for hospital pharmacists to be 9.8%. This is approximately three times greater than the replacement factor for other branches of pharmacy. In spite of the rapid turnover, hospital pharmacy has been and I believe will continue to be the most rapidly growing and dynamic area of specialization within the profession. However, thinking leaders in pharmacy cannot afford to overlook the advantages to be gained by making long-term careers in hospital pharmacy more attractive.
I believe the following situations are largely responsible for the rapid turnover of pharmacists in hospitals. First, too many hospitals have failed to provide challenging opportunities for hospital pharmacists and, second, they have failed to pay hospital pharmacists sufficiently to compete with other areas in pharmacy for top level people. Third, pharmaceutical education has failed to prepare undergraduate students to recognize career opportunities in hospital pharmacy and, finally, too many pharmacists have failed to recognize that most of the opportunities in hospital pharmacy come disguised as hard work.
Hospitals that fail to provide a climate for professional growth in depth and breadth are not likely to attract and hold progressive pharmacists for very long. Providing a growth climate includes many factors. First is acceptance as a professional department head. Next is recognition of the needs for adequate physical facilities for the pharmacy, including a well-equipped laboratory so that pharmaceutical procedures can be carried out properly. Here I am not thinking so much about bulk compounding but rather adequate space and the equipment needed to provide those pharmaceuticals essential to high quality patient care that are not commercially available. Sufficient personnel is important too – not only to provide adequate service but to permit the pharmacist to have the time to work closely with the medical, nursing, and administrative staffs of the hospital and to take part in hospital committee activity.
To have a full and satisfying career, hospital pharmacists need to do some teaching and have the opportunity to further their own education. The pharmacist must also have time to participate in professional meetings and to attend institutes and refresher courses. He should be encouraged, preferably by financial assistance, to pursue academic studies. Highly necessary, and yet difficult to define, is freedom of movement. To me this means the freedom to operate the department, within the general policies of the hospital and in keeping with the standards of practice and ethics laid down by the profession. Finally, he needs the assignment of additional responsibilities, from time to time, to provide new challenges and to sharpen his managerial
ability. Here, I would like to say that it is my good fortune to be affiliated with a hospital that offers all of these opportunities and more.
One of the more serious problems facing career hospital pharmacists today and in the immediate future is this matter of income or, more accurately, the lack of it. Hospital pharmacists, in common with other American citizens, have every right to get married, have families, go into debt, provide summer vacations for their families, and send their children to college. Many hospitals recognize these and similar desires for all their personnel and in recent years have done much to institute salary scales comparable to similar jobs in the community.
For the most part, salaries for staff pharmacists in hospitals have been elevated to compare favorably with other employed pharmacists. Hospitals that have failed to do this have simply failed to get their share of available pharmacists.
The pharmacist-in-charge has not always fared so well. In many cases, his salary too has been limited by the going rate paid to employed pharmacists in the community rather than being based on the income of those pharmacists with significant managerial responsibilities. This unfortunate situation has forced some career hospital pharmacists to accept part-time employment in community pharmacies and, in a significant number of cases, to seek full-time employment in other branches of the profession.
Hospitals must realize that to hold well-trained, mature pharmacists as department heads, they must pay them sufficiently well to enable the pharmacists to provide a standard of living for their families on a par with other successful professional people in the community.
The educational needs of the hospital pharmacist need reexamination and study. Today, undergraduate orientation courses are not uncommon, and almost one-half of the colleges of pharmacy now offer graduate work in the area of hospital pharmacy. Many of these programs are quite new and reflect the growing popularity of graduate study in all phases of pharmacy. I am inclined to think that we now have too many rather than too few graduate programs in our specialty. If this is true, it is our own fault since many of the programs resulted from the stimulation, clamor, and pressure from hospital pharmacists for the colleges to do something about graduate education in our area.
Without attempting to force all hospital pharmacy graduate students into the same mold, I would like to see fewer and stronger programs. Since the hospital pharmacist as a practitioner will be concerned primarily with drug therapy, it seems to me that it is important for him to be thoroughly grounded in the biological sciences. Advanced work in physical pharmacy, product formulation, and the like is necessary for background. However, primary emphasis should be placed on advanced work in pharmacology, biochemistry, and microbiology from a patient-oriented point of view. The college of pharmacy, which is an integral part of a medical center complex, is ideally situated to provide a strong graduate program in the area of hospital pharmacy.
By reducing the number of graduate programs in hospital pharmacy, sufficient students would be enrolled in each program to permit courses to be offered in the proper sequence. This would allow completion of the academic portion of the program in one calendar year. The second year would then be devoted to an internship which the student would spend with a qualified preceptor. The primary purposes of the internship would be to teach the intern managerial skills and to expose him to the day-to-day problems in the operation of a hospital pharmacy.
Since we have a solid core of well-trained hospital pharmacists, many of whom would welcome the opportunity to participate in preceptor programs, the problem of internship accreditation that has haunted us for the last decade would be partly solved. Certainly no internship program, regardless of the hospital, will be any better than the preceptor.
At the risk of being labeled well meaning but misguided, I would like to make a comment or two about the ultimate aim of the graduate programs in hospital pharmacy and the degree to be awarded. In the past, we seemed to have been confused. Some programs have offered professional degrees through the college of pharmacy while others have offered academic degrees through the graduate school of the university. Unfortunately, the confusion has not been limited to just the type of degree but also to the purpose of the program, and I think they go hand in hand. I can see only one purpose for graduate programs in hospital pharmacy and that is to train practitioners. Every phase of the program should be directed to this end, and the degree should be considered terminal. We are not training teachers or researchers or providing a steppingstone for a Ph.D. This does not mean that the occasional hospital pharmacy graduate student could not and should not alter his plans and elect to teach, become a full-time researcher, or go on for a Ph.D. It does mean, however, that as in the case of the M.D. who elects to earn a Ph.D. in pharmacology or physiology, it will be more costly to him in terms of time.
If graduate programs in hospital pharmacy are geared to producing practitioners, the degree should be one comparable to that awarded to others in the health profession who have completed six years of academic work plus a year of internship. Thus, it would appear that the Pharm.D. or doctor of pharmacy degree would be most suitable for the graduates of such a program.
I am impressed with the caliber of pharmacy students these days. They are intelligent, alert, and eager to learn. There is some evidence that the students are changing faster than the colleges. While studies indicate that 85 to 90% of the current graduates enter retail pharmacy, these studies cannot show the percentage of the current graduates that will practice in hospitals sometime during their career. However, it is generally accepted that approximately 30% of the legend drugs now flow through hospitals. Further, it is anticipated that hospital drug purchases may account for as much as 50% of the legend drugs that will be sold in 1975. This can mean only one thing: many more hospital pharmacists will be needed in the years ahead. It would appear that the colleges of pharmacy must alter their approach if their graduates are to be equipped adequately for the future. Strong orientation courses in hospital pharmacy at the undergraduate level should be offered and the lectures supplemented by required visits to hospitals in the community.
At the University of Tennessee, hospital pharmacy is a required course for seniors.
As part of the laboratory exercise, the students in small groups spend three hours in each of four hospitals. An attempt is made to expose the student to what takes place in the hospital and give him some idea of what constitutes adequate pharmacy service.
Now in its third year, this program is too young to evaluate. However, the students have shown considerable interest, and we believe this experience will be of value to them in later years should they enter hospital practice on either a fullor part-time basis. It stands to reason that another by-product of this program will be the better understanding which will result between hospitals and the community pharmacists. Although no emphasis is placed on hospital pharmacy as a career, you will be interested to know that 20 students out of a senior class of 78 have indicated some interest in hospital pharmacy following graduation.
In the past, we have spent much time in proving that pharmaceutical service is essential in all hospitals regardless of size. For the most part, we recognize that many hospitals, particularly those of less than 75 beds, cannot afford the services of a fulltime pharmacist and, if they could, pharmacists would not be available. While we have suggested that these hospitals should seek the services of a pharmacist in the community, we have not done all that we could in bringing about a working relationship between the small hospital and the community pharmacist. It is estimated that only 500 out of the approximately 4000 hospitals that do not have a pharmacist on their staff utilize the services of a community pharmacist.
Hospital pharmacists must provide the leadership necessary to bring the administrators of hospitals too small to require the services of a full-time pharmacist together with the community pharmacists interested in hospital affiliation. This program should also be expanded to include nursing homes. By assisting in the establishment of working relationships between small hospitals, nursing homes, and community pharmacists, hospital pharmacists will be fulfilling one of the major objectives of the ASHP and at the same time assisting the profession as a whole.
As Chairman of the House of Delegates of the American Pharmaceutical Association for the past two years, I have been exposed at close range to many of the problems confronting American pharmacy. We would be less than realistic if we fail to recognize that we do have many serious problems – problems that need the attention of every thinking pharmacist in the United States.
It has often been a source of considerable disappointment to me that hospital pharmacists have not taken a more active part in pharmacy affairs in their communities and throughout their state. Hospital pharmacists do have an obligation to the profession, and they should measure up to this obligation. We should certainly carry our own weight, and to do this we must know what is taking place in local, state, and national pharmaceutical affairs. I have no patience with hospital pharmacists who clamor for representation on state boards of pharmacy and public health committees and want to influence pharmaceutical affairs in their area when they make no effort to share in the solving of problems of total pharmacy.
No other group has the opportunity to contribute so much towards the professional survival of pharmacy as do the pharmacists practicing in hospitals. Medical practice is now centered around hospitals. The hospital is where the medical student is first exposed to the use of drugs. Experience, good or bad, with pharmacy service in the hospital as a student, intern, and resident will make lasting impressions which the physician will carry into private practice.
As good citizens, hospital pharmacists have obligations to take an active part in community affairs, service clubs, church activities, and the volunteer health agencies. The hospital pharmacist will find that in order to have a satisfying career, it is necessary for him to contribute to both his profession and his community.
This is an exciting time to be in hospital pharmacy. Many of the future breakthroughs in the medical sciences will be in the area of drug therapy. Throughout our lifetime, hospitals will continue to undergo dynamic growth in size and complexity. Where we go from here will depend largely on our ability to continue to learn and, more importantly, on our ability to change.
Already studies are going on in hospitals across the nation that will revolutionize the distribution of drugs and other pharmacy practices. The day of disposables is here. Within the next few years, almost all small volume injectibles will be dispensed in self-contained units with needles attached ready for administration. None of us here tonight would care to guess if strip packaging, unit dose dispensing, automation, and decentralized pharmacy services will win out over the highly centralized, efficient pharmacy equipped with a battery of electronic devices to transmit medication orders instantaneously to the doctor’s handwriting.
One thing for sure, the role of the hospital pharmacist will become increasingly important and complex. However, even in the days ahead, the teachings of Harvey A. K. Whitney and his followers will remain valid. Tom Reamer, one of my preceptors, described Mr. Whitney as a man not satisfied with slow growth. Neither can the hospital pharmacist of today be satisfied with slow growth.
Where we go from here will not depend so much on unusual intellect or gifted vision but on our dedication to do those things we know should be done. The art of work and the realization that people, not organizations or machines, get things done will continue to be as important in the future as they have in the past.
Despite world tensions and the sometime seemingly insurmountable obstacles confronting our profession, I view the future optimistically and with enthusiasm. In the words of the poet Henry van Dyke:
This is my work, my blessing, not my doom.
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Hosp Pharm. 1962; 19:304-9.
© 1962, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.