We Really Do Care
Iam sincerely honored to join the family of Harvey A. K. Whitney Award recipients and would like to thank the selection committee for this special evening. As you have learned, I retired as director of pharmacy at Montefiore Medical Center on March 4th of this year. That event, and with it the thanks I received for 29 years of service, would have been enough to keep me on cloud nine for many years. So, when only four days after leaving Montefiore I received a call from Dr. Oddis telling me of this honor, I believe to say that I was walking on air would be the understatement of the year. Of course, Joe quickly reminded me of the responsibility that goes with this honor.
The late Donald Brodie, a personal acquaintance of Harvey A. K. Whitney, characterized him as a man who motivated and inspired people.(1) During his career, Whitney developed a cadre of disciples who, in becoming leaders of the pharmacy profession, advocated the Whitney ideals of practice, education, and organizational involvement. Although I did not have the opportunity to know him, I was very fortunate to have been influenced by many pharmacy leaders, people like Arthur Purdum, Norman Hammelman, Paul Parker, and Clifton Latiolais, who espoused the Whitney philosophy. Norm Hammelman was my preceptor and mentor at the VA hospital in St. Louis, and I will always be grateful to him for the opportunities he gave me to learn and develop. Paul Parker and Clif Latiolais, whether they know it or not, had a significant influence on my early professional growth and my career. They all cared.
“We really do care” is the theme I have selected for this evening. “Care” and “caring” have become popular words these days. I chose this theme because I would not be alive today, nor recognized professionally by you, if many had not cared. Mothers, we know, are expected to care for their children. My parents had four children, of whom I was the youngest. With us this evening are my sister, Edith, from Florida, and my brother, Fritz, who still lives in Vienna, Austria. In February 1941, because of the indescribably bad conditions in Vienna, my mother cared so much that she found the means to send me, then an 11-year-old, out of that city. She didn’t know what might happen to me or whether she would ever see me again. I don’t know how she arranged this, and I do not remember her or my other sister Herta’s goodbye. Somehow I have blocked this out of my memory. When I left Vienna in 1941, my brother and father had already been in Nazi concentration camps for two years. How my father and brother survived the six years they spent in the camps is for me a miracle. Fritz is living proof that the Holocaust did occur, and he describes the experience during regular visits to schools in Austria and writes about it. I can’t help but think that caring is not in the vocabulary of the few who still deny that 6 million Jews, and many others, were murdered by the Nazis. Many died in those infamous gas chambers.
A family in New Bedford, Massachusetts, cared about the events happening in those days. Judge Samuel Barnet and his three sisters, Sarah, Kate, and Esther, heard that a young boy was arriving in the United States without his parents and needed a home. They accepted me as if I were their own. “Unkle” Sam was like a father to me, and of course I also ended up with three new mothers. They taught me their values. I will share with you one technique that helped me face reality. Judge Barnet took me to the local jail to see what happens to people who don’t behave and don’t respect their fellow human beings. I was told, “If you don’t behave, this is where you will end up. Then all you can expect is a pillow, a blanket, and a daily loaf of bread.” I suppose if more youngsters were given that lesson today, and if people cared more about others, there would be less violence.
As you know, W. Arthur Purdum was the first Whitney Award recipient. I had the privilege of practicing under Dr. Purdum at The Johns Hopkins Hospital in my early hospital pharmacy days. In his 1950 Whitney lecture he stated:
A final consideration is the threat of compulsory national health insurance. Our public servants in Washington have made John Q. Public well aware of the high cost of medical care. The paying hospital patient is indignant over the high per diem cost of hospital care, and it is true that these costs have risen considerably in recent years. But he overlooks the important fact that advances in the pharmaceutical and medical sciences have substantially reduced the term of his stay in the hospital.(2)
This description could have been taken from yesterday’s New York Times or this evening’s television news broadcast. Yes, medical care is still one of the high-cost items in our economy, and while we, as pharmacists, continue to make significant progress not only in the sciences but also in pharmacy practice, the average patient is still not aware of all the activities that a pharmacist performs. In addition, some health care administrators are not yet convinced that pharmacists can be effective in cost-reduction programs. Yes, we still have much work to do.
Dr. Purdum greatly influenced my career. He is the one who taught me entrepreneurship. When he promoted me to supervisor of production he indicated that I could do anything I wanted within my area as long as it didn’t cost anything. Did I learn to barter! He empowered me and others before that word was even in our dictionary. When we needed to know how to make something, he provided a book and said learn. And we did. He imparted not only his philosophy of practice but his passion for pharmacy.
There were of course many others in my professional life who cared and who influenced me. It was Peggy Sherwood Oppedal, a Johns Hopkins resident at the time, who told me, “If you want to be a leader in hospital pharmacy, you had better obtain a residency.” Yes, residencies were geared to developing leadership in those days.
I believe that, as far as the patient is concerned, we have always cared. However, our focus was different. During the compounding and manufacturing era of the 1950s, we cared by preparing an elegant drug product in accordance with stringent quality-control procedures. During the unit dose era, our caring was expressed in eliminating some of the drug-related manipulations that nurses performed, ensuring that patients received their drugs, and decreasing the medication error rate. The clinical pharmacy era had pharmacists providing drug information, doing pharmacokinetic monitoring, and engaging in other activities centered on the drug. These services were primarily geared to the physician. The development of formularies and the use of generic equivalents and therapeutic alternatives emphasized the economics of drug selection.
Today, our emphasis is on pharmaceutical care—providing for the best use of drugs for the direct benefit of the patient. Are we as pharmacists willing to take full responsibility for our actions? Do the medications we provide restore patients to health or at least improve their quality of life? The answer must be a resounding yes, but our actions must correspond with our words.
I am a sailor, as some of you know. To be a good sailor, one must shift to a new tack, or “come about,” as the wind changes. I recently saw a poster with the statement, “We cannot direct the wind, but we certainly can adjust the sails.” With clinical pharmacy, we were on the right course. However, with the health care system in transition, the wind has shifted toward the patient and toward providing quality care at affordable cost. Pharmaceutical care has become pharmacy’s mandate and will reprofessionalize those who embrace it.(3,4) The profession has reached a consensus on pharmacists providing pharmaceutical care. We realize that not all pharmacists may know what pharmaceutical care is and how they must practice it; some may not even yet have the knowledge to perform it. We must teach them to adjust their sails and come about. With the excitement over pharmaceutical care, however, also comes a warning in the wind. As Ken Barker stated, “We must be careful to practice what we preach and not merely follow our leaders with rhetoric.”(5) Slogans alone won’t make it. Pharmacists are not the only caregivers to provide pharmaceutical care. Therefore, I question those who have decided that the fastest way to practice pharmaceutical care is to suddenly become a department of pharmaceutical care without the need for a complete mind change. Barker labeled this kind of activity “pseudopharmacy” years ago.(6
At Montefiore, we were only starting to implement pharmaceutical care when pharmacists were authorized by the medical staff to change specific drug orders and dosages without the physician’s explicit permission. I was planning, as my next step, to have Montefiore’s physicians certify our pharmacy specialists, such as those practicing in infectious diseases or family practice. Once they had been certified as competent, I was going to seek approval for these specialists to expand their authority, within their specialty, to making changes in drug therapy and dosages without being limited to specific drugs or dosages. I was hoping to take us beyond the practice of merely ordering drugs according to approved protocols. But I retired before we were able to finalize the concept. I have no doubt that in the near future pharmacists will have prescribing authority even beyond my expectations.
An important feature of pharmaceutical care is that it should provide continuity of care when a patient is discharged from the hospital or readmitted. This continuity of care provides more than integration of services. It gives a signal to the public of our professional unity with our community pharmacist colleagues. The national dialogue by pharmacy organizations held through the Coalition for Consumer Access to Pharmaceutical Care and the Joint Commission of Pharmacy Practitioners is an excellent endeavor in this direction. We now must encourage this same kind of dialogue at the state and local level. We must encourage ASHP members to have a greater sensitivity to the problems facing our colleagues in community practice. Economic survival is not merely an institutional problem.
Change is upon us. It is here, today. Those who cannot adapt may not be here tomorrow. But we have always progressed most during times of adversity. Hospitals today are downsizing. Mergers and acquisitions are taking place. We are witnessing the formation of integrated health care systems. Teaching and community hospitals are forming networks and coalitions. Patient-focused care is becoming a widespread concept(7); it is expected to increase hospital productivity, simplify work, provide for interdisciplinary collaboration, and empower patients. An improvement in patient care is projected, as well as potential reductions in costs. For some, patient-focused care spells the impending demise of pharmacists and pharmacy departments. I see it as an opportunity: an opportunity to become a member of the patient care team, an opportunity to implement pharmaceutical care. The danger comes if we allow pharmacists to become completely separated from the department or if the attempt is made to eliminate the department altogether. Bill Zellmer, in giving advice to hospital executives, suggested that lowering the profile of the pharmacy department would be counterproductive.(8 )He advised them to do just the opposite. Support the pharmacy, he suggested. In these difficult times of cost control, greater competition, pharmacy moving to a patient-focused profession, and increased use and sophistication of pharmaceuticals, proactive pharmacy leadership will be required more than ever.
It is, therefore, our own leaders in pharmacy, not outside consultants, who must shape our destiny and decide the changes that are necessary. What about pharmacy directors? Are they an endangered species, as recently headlined? Who will integrate our vision with respect to pharmacy technicians, clinical skills development, automation, and new, innovative patient care programs?
As long as pharmacy directors maintain their ability to practice pharmaceutical care, they will not become an endangered species. For years, I encouraged my B.S.level residents at Montefiore to obtain a Pharm.D. degree irrespective of the area of pharmacy in which they wanted to practice. I also advised them that if they became directors of pharmacy, they should function like chairmen of medical departments who spend the equivalent of at least one day a week in clinical practice. Others have espoused the similar sentiment that future directors will come from the ranks of clinical practitioners.(9,10) I agree: We are a clinical profession, and our department is a clinical department. Let us demonstrate it by our professional actions. Who knows, in time we may not have to use the word “clinical” again. I therefore urge the colleges of pharmacy to accelerate the process of implementing the entry-level Pharm.D. as the first degree for pharmacists. We cannot delay academic changes while advances in biotechnology, gene therapy, and other technologies, make the knowledge of today’s graduates obsolete within a few years.
There are other elements for future success I want to mention. To achieve our goal of caring for patients, we still need physicians and administrators as our allies. Being a pragmatist, I know that our success in providing care to patients will depend on the physician’s perception of the value of the pharmacist. Administrators will continue to hold the purse strings, and the competition for limited hospital resources will persist. We cannot be successful with administrators in obtaining our share of resources without being successful with physicians. Part of this success will be contingent on the pharmacist obtaining some autonomy in drug prescribing.
Another vital element for success will continue to be hard work, accepting responsibility, and giving more than one is asked for.(11 )I am reminded of the time when we asked a residency applicant to tell us what a leader is. The candidate answered, “That’s easy. One thousand cc’s.” A leader provides more than that—at least eleven hundred “cc’s”—which, to those of us who used to work “on a soda fountain,” always included the “shaker on the side.”
I have been involved in residency training for many years. Residency programs have provided the foundation for the development of leaders in hospital pharmacy. This benefit can be attributed to the mentor–resident relationship. The revised residency standards emphasize training in the provision of pharmaceutical care. The training schedule, however, must also provide sufficient time for fostering the mentor–resident relationship if the resident is to acquire the practice philosophy we are speaking about. Future leaders will then continue to emerge of the caliber of a Harvey Whitney, a Don Francke, a Gloria Francke, a Herbert Flack, a Sister Gonzales Duffy, a Paul Parker, and a Clifton Latiolais.
As I implied earlier, one cannot achieve this sort of recognition by oneself. Special thanks go to my wife, Dianne, who has always supported me in my professional endeavors—since the day we got married and moved halfway across the country to St. Louis while expecting our first child. Thanks also go to our sons, Bill, Paul, and Jim, who have joined me in caring for my other loves, skiing and sailing. I extend my appreciation to all those at Montefiore Medical Center, both in the pharmacy department and in administration, who made it possible for me to achieve some measure of success. Finally, I give my thanks to all the residents with whom I had the pleasure of being associated—many of whom continued to work at Montefiore after their residency and therefore were instrumental to our many successful programs.
With this honor goes responsibility. While I have retired from active institutional practice, I have retained my faculty appointment at the Arnold & Marie Schwartz College of Pharmacy and Health Sciences at Long Island University. I will, therefore, continue my efforts to instill the Whitney practice philosophy in students and young practitioners . . . because we truly do care.
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Hosp Pharm. 1994; 51: 2011-5.
© 1994, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.