An Iconoclastic Perspective on Progress in Pharmacy Practice

The opportunity to deliver this year’s Whitney Lecture is the consummate
honor of my career. I accept the award in recognition of the many
colleagues, residents, and students who have helped me learn and grow
over the years. In The Human Condition, political philosopher Hannah Arendt said,
“For excellence, by definition, the presence of others is always required.” Harvey A.
K. Whitney’s work in the pharmacy department at the University of Michigan Hospital
began a tradition of excellence and accomplishment in our profession. Whitney’s
successor was Don E. Francke – in my mind, this century’s greatest pharmacy thought
leader and practice innovator. I served a residency with Don Francke, and I am particularly
indebted to him for his guidance and mentorship. Tonight’s celebration is
not so much about honoring the individual recipient as about reaffirming our purpose
as a group of committed professionals. I’d like you to join me in revisiting and
reassessing some elements of our progress in pharmacy practice.

Observations on my journey

Some might view me as a soldier of fortune, since I have held six positions as a
director of pharmacy, the last three of these in academic medical centers. But I can
assure you that my professional itinerancy was not a quest for a higher salary or more
prestige. Each of my six pharmacy director positions represented a road less traveled
for me as a professional – an opportunity to reinvent myself, to transform practice to
a higher level than what I found upon arrival, and to leave some footprints. During
my journey, I have learned much about myself and my profession.

I speak tonight from an iconoclast’s perspective, in part because the tradition of
excellence that we celebrate this evening is the borne fruit of iconoclasts – people
who sought to challenge and overthrow accepted beliefs. Leaders and practice innovators
from every era of hospital pharmacy have been iconoclasts. Thought leaders
like Doug Hepler, Bill Zellmer, and the late George Provost have challenged us to
change our professional philosophy. They have changed meaning for us. Pharmaceutical
care exemplifies this evolution in philosophy; it has recast pharmacy in a new
context with a more compelling meaning.

Iconoclasts profess that not all is well and that things can be improved. From this
perspective, I will comment on several areas:

  • The disparity between the profession’s purported level of practice
    and reality,
  • Some of the forces and trends shaping and influencing our progress
    and destiny, and
  • The profession’s ongoing quest to reconcile its interest with its

What the numbers tell us

By most objective standards, pharmacy practice in the acute care setting has advanced
substantially in the past four decades. The first comprehensive survey of the
status of pharmacy practice in hospitals was conducted in 1957, and the results were
published in 1964 as Mirror to Hospital Pharmacy.(1) The document contained a prophetic
foreword by Joseph A. Oddis, then Executive Secretary of the American Society of
Hospital Pharmacists. Oddis called the survey results “truths more revealing than we
would like them to be.” Yet, he said, “It is only in knowing these truths that we will be
able to proceed toward orderly improvements. For the first time, we can work from
the truth.”

The publication of the Mirror was a watershed marking the beginning of ASHP’s
commitment to improving pharmacy practice in America’s hospitals and fulfilling
our social purpose as a profession. Our progress is documented in nine subsequent
surveys conducted by ASHP, the latest of which was published this month.(2) Moreover,
thanks to the work of Cindy Raehl, “Cab” Bond, and their colleagues, we now
have detailed information on our progress in advancing clinical services.(3,4) Their recent
work suggests some good news about pharmacy’s contribution to reduced hospital
mortality rates.(5)

Still, considerable work remains for us in advancing practice, especially in view of
pharmacy’s newly avowed purpose of pharmaceutical care. The survey results, when
viewed across three decades, are impressive, but it is my belief that our progress is
equivocal at best, especially over the past 10 years. Reviewing the results of the nine
surveys elicits more questions than answers. It compels an iconoclast to view the
glass as not half full but half empty.

The ASHP survey results indicate that great progress was made in the decade from
1974 to 1985 on virtually all practice fronts.(6,7) In fact, there was a fourfold increase in
the number of hospitals that reported having complete unit dose distribution and i.v.
admixture services, 24–hour service, and some basic elements of clinical services.
These surveys, of course, depend on self–reporting, which may very well bias the
results. But during that decade hospitals reporting having both a complete unit dose
drug distribution system and an i.v. admixture service increased from 10% in 1974 to
50% in 1985; 24–hour pharmacy service moved from 6% in 1974 (only 17% for large
hospitals) to 43% in 1985 (72% for large hospitals). However, only 10% of hospitals
had “comprehensive services”: complete unit dose drug distribution and i.v. admixture
services plus three or more clinical services that were defined in the survey instrument.

A decade later, the ASHP survey indicated that 64% of hospitals have both complete
unit dose drug distribution and an i.v. admixture program and that gaps still
exist in 24–hour pharmacy coverage. Although it is difficult to gauge precisely, about
one in three hospitals has comprehensive services as defined by the ASHP survey
instrument. What is more, 8% of the surveyed hospitals in 1994 did not have the
services of a pharmacist for more than 10 hours per week.(2,8) Interestingly, 88% of the
survey respondents reported some level of computerization, but 84% of the responding
hospitals do not have a direct order entry option for prescribers and only 8%
expressed the intent to develop such a capacity in the next year. Official ASHP policy
states that direct electronic order entry is the preferred method of prescribing.

The statistics cited for clinical services in the 1994 ASHP survey are also quite
revealing upon close examination. The most commonly reported clinical services
were adverse drug reaction surveillance programs, medication error management,
patient counseling, and drug–use evaluation; about 50% of the respondents had these
services. Such services, I would remind you, are explicitly required by the Joint Commission
on Accreditation of Health Care Organizations. Fifty–three percent of the
respondents noted that pharmaceutical care, as described in the ASHP Statement on
Pharmaceutical Care,(9) was provided to virtually none of their patients. Moreover,
less than one third of the respondents provided this level of care to less than 25% of
their patients. Raehl, Bond, and colleagues, in their 1989 and 1992 surveys, also
reported that even the most common direct patient care services were provided to
only a small number of inpatients. In fact, if one adjusts for the high percentage of
respondents offering adverse drug reaction reporting, drug–use evaluation, and inservice
education, most services (with the exception of pharmacokinetics, at 54%) are
below the 45% level of implementation.

Too often, I believe, we are long on talk and short on action when it comes to
changing our level of practice. How can we, in good conscience, make the case for a
transformation to pharmaceutical care for the mainstream of patients when, to date,
we have not yet made such a transformation for those patients who are acutely ill in
our hospitals and who are in greater peril of drug misadventuring by virtue of their
disease acuity and level of drug therapy intensity? If such care is so critical, why is it
not being demanded in hospitals?

Practice standards and reality

Effective and safe drug therapy is a major determinant of the outcome of acute
care. Yet, our objective measurements indicate that our progress may have slowed
considerably. Our adherence to the substance and spirit of the standards contained in
the 243 pages of the Practice Standards of ASHP 1994–95 is still a far–off vision for all
too many of us practicing in hospitals. I never cease to be surprised at the enormous
gap between what is said and written about hospital pharmacy service programs,
levels of practice, and “big names” (especially at major teaching hospitals and academic
medical centers) and what actually exists in those settings. There are pharmacy
departments all over this country whose scope of service and general stature within
their own hospitals are a far cry from the ideals and goals of the profession. Here
are a few examples:

  • In a large hospital in a major metropolitan area, cancer chemotherapy
    is prepared by nursing personnel on nursing units, with little
    or no connection to pharmacy.
  • In some academic medical centers, clinical pharmacists who are
    designated as clinical faculty of colleges of pharmacy have virtually
    no service responsibility or formal organizational accountability
    through the hospital’s pharmacy service. It is questionable whether
    such faculty members could justify their existence as practitioners in
    the absence of students, yet we expect future generations of pharmacists
    to see them as role models.
  • Clinical pharmacists are sometimes assigned to and funded by
    medical departments with virtually no linkage to the pharmacy
    department’s service mission.
  • In pharmacy departments with highly differentiated levels of practitioners,
    “clinical pharmacists” (or in some cases, “pharmaco341
    therapists”) are exclusive providers of what I would term boutique
    clinical services. What happens when these providers are ill or on
  • Positions of directors of pharmacy are being eliminated, as part of
    “operations improvement” or “re–engineering” efforts. Are positions
    of clinical director of radiology or laboratory medicine or chief of
    medical staff ever eliminated?
  • In too many hospitals, the recruitment of a director of pharmacy
    assumes as much importance as a decision to change sources of
    supply of commodity products in the hospital’s general stores unit. It
    has always been my fervent contention that the position of director
    of pharmacy is as critical to a hospital’s mission as any other clinical
    service directorship. Hospitals that ignore this tenet diminish their
    capacity to accommodate to rapid change in their operating environments
    or to contribute to the achievement of desirable clinical or
    operational outcomes.

I have always been offended by a pharmacy department that is either nominally or
functionally relegated to ancillary service status. The dictionary defines ancillary as
“subordinate, subsidiary” or “inferior in order or importance.” How does this square
with a belief that the services of a pharmacist are critical? I realize that the term
ancillary may be only a conventional designation, but too often it has more significance
than we would care to admit.

I sense that thousands of pharmacists in America’s hospitals, and tens of thousands
in other settings, are leading “lives of quiet desperation,” to use the words of Henry
David Thoreau. Thoreau might have been describing pharmacists’ situation when he
wrote, in Walden:

What is called resignation is confirmed desperation . . . . It appears as if men had deliberately
chosen the common mode of living because they preferred it to any other . . . , they honestly think
there is no choice.

Are there no other choices for these pharmacists?

The unmet need for medication management

Drug misadventuring and iatrogenic drug–related injury are now described as major
public policy issues. In 1989, Henri Manasse(10,11) described the problem in a clear
and detailed fashion. A short time later, Brennan, Leape, and coworkers(12,13) provided
unequivocal evidence of the incidence and nature of adverse events in hospitalized
patients. They found that 19% of the adverse events were drug related. Recently, in
The Journal of the American Medical Association, Leape(14) projected that iatrogenic injuries
in hospitalized patients cause at least 180,000 deaths per year, which he said was
“the equivalent of three jumbo jet crashes every two days.” (Not all of these fatalities
are drug related, of course.) The public has had little awareness of the severity of the
problem of hospital–acquired injuries. Leape noted that such injuries are not widely
reported by the media because they occur one at a time in 5000 different locations
across the country. Some highly publicized recent events indicate that this may be

Findings on the prevention of prescribing errors by pharmacy departments(15) and
the presentations at ASHP’s Conference on Understanding and Preventing Drug
Misadventures(16) further describe the unmet need for effective medication management.
The iconoclast would ask, Have we really made that much progress when the
most fundamental elements of drug–use control and clinical services for preventing
drug–related error are still considerably out of our grasp?

For at least a decade, our colleagues Neil Davis and Michael Cohen have been
promoting awareness of the importance of preventing drug misadventuring, and significant
progress has been made. Since the 1985 Hilton Head Conference on directions
for clinical practice in pharmacy(17) and the dissemination of Hepler and Strand’s
concept of pharmaceutical care,(18) many pharmacists have earnestly begun transforming
their philosophy of practice. Some – a minority – are developing an organizational
structure that facilitates pharmaceutical care. The profession has been trying desperately
to make a crucial cultural transition that Zellmer(19) described as “bringing
pharmacists rather than pharmacies closer to patients” to act as their advocates.

Whither pharmaceutical care?

Virtually all of pharmacy’s practice constituencies have embraced a new purpose –
helping people make the best use of their medications. The concept of pharmaceutical
care has provided a basis for reprofessionalization as well as an organizing purpose
for pharmacy practice. If we fully embrace the concept on a personal level, it
also offers the promise of dignity and self–esteem for individual practitioners.

Hepler and Strand(18) described pharmaceutical care as a maturation phase for pharmacists,
not unlike a person’s reaching social maturity. It reflects an expectation that
one thrives by using one’s power to serve something bigger than oneself as well as
accepting responsibility for one’s actions. Hepler and Strand acknowledged the implicit
bureaucratic constraints that make such maturation and transition difficult. Hepler(20)
had previously described this maturation to pharmaceutical care as the synthesis
of two core activities: dispensing pharmacy from the pre–1960s era and clinical pharmacy
that subsequently emerged.

Despite the widespread support for pharmaceutical care, some perceive it as either
the exclusive domain of an elite corps of clinical pharmacists or merely the old wine
of clinical pharmacy in a new wineskin called pharmaceutical care. It concerns me to
see the term bandied about by drug companies trying to market products and by
pharmacy benefit management companies whose express purpose often appears to
be controlling costs rather than maintaining patients’ health.

It is much too early to predict whether pharmaceutical care will take root and
flourish. I hope my cynicism is not warranted; what we are witnessing could be the
crystallization of an idea and the challenges of early adoption and diffusion. But one
thing is certain: We have a national problem of drug misadventuring that results in
significant morbidity and mortality, ineffective care, and unnecessary and unacceptable
costs. It is incumbent on all health professionals to “first do no harm,” and to
work to restore health; pharmacists practicing pharmaceutical care can make a major
contribution. Pharmaceutical care will not emanate from professional organizations,
the educational establishment, or the profession in a collective sense, but from individual
practitioners and leaders in practice environments.

Trends in the profession and society

Individual pharmacists need will as well as skill for the profession’s cultural transition.
I believe we have become preoccupied with imbuing individuals with skill at
the expense of will. Witness our preoccupation with the Pharm.D. degree. We may
have unconsciously created a generation of newly educated and trained practitioners
who seek what I term “turnkey” clinical practice positions instead of opportunities to
create new practice models or, better still, to elevate less–than–optimal practice. Such
attitudes may have their roots in unrealistic clinical faculty role models, simulated
residency training programs, and a professional literature that promises more than is
being delivered. The slow pace of progress in elevating practice standards in hospitals
could be related to such mindsets, but I sense that the problem is more complicated.
For one thing, clinical pharmacists were in great demand during the past decade,
and positions were filled by individuals who possessed the Pharm.D. degree but had
little or no experience. When some naive directors of pharmacy failed to effectively
nurture such practitioners, the problem grew worse.

The slowdown in growth of health care job opportunities may be starting to sober
up the current generation. Recent figures from the U.S. Department of Labor show
that, in 1994, 254,000 new jobs were created in the health care sector, representing
just 10% of all new jobs in the economy. In contrast, there were 388,000 new health
care jobs in 1990, one fourth of all new jobs. Moreover, there now appear to be more
practitioners chasing fewer attractive positions.

The sustained progress in hospital pharmacy practice from the early 1960s to the
mid 1980s was, in part, a reflection of a health care policy agenda that operated on
the deficit model: If we made up for capital and human deficits in the system, it
would function well.(22) Acute care hospital capacity ballooned from 3.3 beds per 1000
population in 1950 to 4.5 beds per 1000 in 1980. Medical and other health professional
manpower and health services capacity more than doubled in the same period.
Hospital pharmacy owes its great progress during that period to a cadre of strong
leaders, most of whom were nurtured by residency training programs in the 1950s,
1960s, and 1970s, and to ASHP’s promotion of educational programs and practice
innovations in the public’s interest.

Pharmacists entering the profession today face an unprecedented challenge to improve
medication management, as well as the challenge of the cultural transition to
pharmaceutical care. For them, will is as important as skill. They need the nurturing
of a profession that speaks the truth and does not shroud its mission and responsibility
to patients, and of an academic community that views the professionalization
process not only as an educational experience but also as a social experience that
inculcates in students the values that will support pharmaceutical care. I am encouraged
by a recent report on changing the culture within our pharmacy schools, which
addresses the linkage of professional socialization and pharmaceutical care.(23)

Managed care’s influence will undoubtedly lead to a further reduction in hospital
bed capacity. The closure of more than 600 hospitals (some 100,000 beds) in the next
five years has been projected. Nationwide health care expenditures in 2000 are expected
to range from $1.4 to $1.7 trillion, with expenditures for hospital care dropping
from 38% to 35% of the overall tab. Forty percent of the U.S. population is
expected to be enrolled in health maintenance organizations and 40% in preferredprovider
organizations. Less than 3% of the population will have traditional fee–forservice
coverage without restrictions on choice of provider. Increasing provider consolidation
and integration will continue as providers seek their market share of fewer
and fewer available dollars.

Slowly, the Medicare and Medicaid populations will be moving to managed care
arrangements; perhaps this is the final frontier for HMOs. Surviving hospitals can
expect profit margins to shrink from an average of 4% to 2%.(24) In short, the growth of
acute care in the 1960s through the 1980s is history.

From my personal observation and my analysis of the last two or three ASHP
surveys, it is increasingly apparent to me that some of our important advances in
practice are beginning to erode, notwithstanding euphemisms like “operations improvements,”
“re–engineering,” and other “big six” management consultant terms.
Ask any hospital pharmacy director how things are going these days, and the answer
is likely to fall between “Lousy” and “We’re holding our own.” Staff are pressed to do
more with fewer resources, and the buffer capacity for what was minimal staffing is
now either marginal or nonexistent.

Given this scenario, residency training opportunities in hospitals, which have been
a wellspring of leadership development, may diminish substantially over the next
several years. It is imperative that new venues reflective of changing delivery patterns
be developed as soon as possible, to prevent further slowing of our progress in
practice innovation and advancement. Directors of pharmacy have an obligation to
develop such opportunities, especially as hospitals become components of integrated
health care delivery systems. Thanks to the leadership and vision of ASHP, we are
positioning ourselves to understand and participate in this structural change in health
care. The conference on integrated delivery systems in July in Chicago is just one of
the strategic initiatives designed to help shape our destiny in this time of change.

Purpose versus interest

Let’s turn now to the matter of our profession’s ongoing ambivalence about reconciling
its interest with its purpose. In his time, Don Francke was the major iconoclast
in pharmacy. He continually reminded us, through his writings in the 1950s, the
Mirror to Hospital Pharmacy in 1964, and his commentary titled “Let’s Separate Pharmacies
and Drugstores” in 1969,(25) that the progress of hospital pharmacy and ASHP
was dependent on the adoption of a philosophy of service that put purpose above
interest. It was this philosophy of purpose that fueled the enthusiasm and passion of
our leaders and individual practitioners during the formative years of hospital pharmacy.
Francke articulated this purpose in 1964 in the Mirror: “To provide pharmaceutical
services as an integral part of the total patient care concept in the interest, safety,
and welfare of the public health.”(1)

In effect, placing purpose above interest is about the profession’s spreading the
truth to its members, society, and its future practitioners. Our newly defined purpose
of pharmaceutical care, which has its roots in the purpose stated by Francke, indeed
represents the maturation of which Hepler speaks. Given the challenges we face today,
including the preoccupation with corporate interests, risk sharing, costs, and
what has been termed the “monetarization” of health care,(26) we face a steep upgrade
in our road to progress in practice. These are “the best of times and the worst of
times”; the promise of pharmaceutical care may well coincide with the opportunities
provided by a drastically changed culture, structure, direction, and system of health
care in America. The safe, effective, and efficient use of drugs as a means of maintaining
health is one of the major unmet needs of our times.

In a recent issue of AJHP, a nonpharmacist member of the Journal’s staff presented
a cogent and riveting consumer perspective of pharmaceutical care.(27) Stephen Kepple
conveyed his experiences: the absence of any level of palpable awareness of the
pharmacist’s role in his own hospital care, let alone any public understanding of the
concept of pharmaceutical care as it has been espoused by the profession. Kepple
may be right on target.

Whether or not the public and payers associate pharmacists with the solution to
the unmet need for medication management is of grave importance to us as a profession.
We have precious little time left to provide convincing reason for our existence.

I see one possible future for the practice of pharmacy already taking shape: a
movement toward two distinct plateaus of practice. I fear that one plateau will be
inhabited by pharmacists who are content with a core activity of dispensing and
traditional prescription service. Where a drug product is treated as a commodity
moving through a continuum of health services and is considered one of many variable
expenses to a health care executive or an employee benefits manager. The pharmacy
practitioners on this plateau will be, by and large, product production managers
overseeing an array of automated dispensing technology and technicians in chain
pharmacies, food outlets, mail order enterprises, and so on. Some of them will have a
very modest role in patient communications; others will not have any. These pharmacists
have, in many instances, already made a personal choice between their interests
and their purpose. I do not in any way choose to demean or denigrate such
pharmacists. It is conceivable that they may face personal economic peril; as profit
margins continue to erode, many corporations (both for–profit and nonprofit) will not
be able to sustain the costs of employing individuals essentially because they are
legally franchised to practice pharmacy by a board of pharmacy. My sincere hope is
that fewer practitioners will be on this plateau than on the other.

Practitioners on the other plateau will be those who have made a conscious choice
to embrace pharmaceutical care as a purpose, on both an intellectual and an emo–
tional level. These practitioners will not view themselves as an elite simply by virtue
of possessing a degree or a pedigree that characterizes them as a hospital pharmacist,
a health–system pharmacist, a clinical pharmacist, a pharmacotherapist, or a clinical
faculty member of a school of pharmacy. Certainly, they will have differentiated practices,
and reasoned specialization will be a fact. They will be pharmacists who function
in different settings along a continuum of health care services to contribute to
optimal health status – a high and noble calling.
The ultimate determinant of our progress is the strength and persistence of will of
each individual practitioner. In terms of the exercise of power, all individuals in a free
society or corporate environment have three distinct choices – exit, voice, and loyalty.
(28) They can leave (exit). They can stay and contribute as expected (loyalty). Or
they can stay and try to change the system (voice).

Importance of organizations and pharmacy schools

Each practitioner’s personal journey as a professional, however, is made possible
and productive through the support of professional organizations that exercise true
leadership – organizations that do the right things and constantly focus their constituents
on their purpose by professing and demonstrating the truth. They consistently
restore our vitality as individuals in the interests of the patients we serve.

Pharmacy’s destiny as a profession is, in large measure, linked to the sense of community
that its practitioners share. Our history of organizational fragmentation and
political posturing will no longer serve us, given the unprecedented changes in health
care. Any group that seeks to place its purpose above its interest must focus on commitment
and not control. Regrettably, we have, through our fragmentation and pursuit
of political interests, concentrated on the latter. I entreat pharmacy’s organizational
leaders to get beyond the rhetoric of purpose and establish some relevant
organizational means, possibly not unlike a federation arrangement, for meeting the
challenge of professional survival.

Our educational establishment is equally critical to the achievement of our destiny.
For too long, the practice community and schools of pharmacy have had an uneasy
relationship. From the 1940s through the early 1980s, the practice community in
pharmacy ceded its claim on influencing its destiny to an academic community that
exalted the basic sciences or the business ethic of pharmacy at the expense of the
advancement of clinical practice. We have paid dearly for the lack of leadership and
commitment to practice innovation in most schools of pharmacy during that period.
The urgent situation in which the practice community now finds itself is partly due to
two generations of pharmacists who, in too many instances, were never truly professionalized.
Professionalization has to begin in school and be nurtured by classmates,
clinical preceptors, and practitioners, not disgruntled pharmacists leading lives of
“quiet desperation.” Fortunately, some practitioners were exposed to excellent role
models or had residency preceptors as mentors; we trusted it to chance, however.

During the past decade, a small but dedicated and persevering new generation of practitioners
who did become properly professionalized and a small number of enlightened
academic leaders have finally begun to forge true partnerships. These partnerships are
built on a commitment to a noble purpose – pharmaceutical care. This bodes well for us.
But such partnerships are far from the mainstream. The unmet educational needs are
great, whether we speak of addressing the needs of the two generations of practitioners
who have not been the beneficiaries of the clinically oriented Pharm.D. curriculum or the
broader issue of effective professional socialization.


Our personal professional journeys are the major determinants of our destiny as a
profession. I hope that your personal professional journey will continue to be as fulfilling
as mine has been and that “we can all work from the truth,” to use Joe Oddis’s
prophetic words from the Mirror to Hospital Pharmacy.


Permit me to acknowledge “the presence of others” in my own personal journey.
My family – Arlene, Steven, and Paul – shared all the peaks and valleys and at times
paid dearly for my being consumed by that journey. I also want to acknowledge my
late parents, Gaspare and Olga Pierpaoli, immigrants who came here without material
resources and without the benefit of any formal education in their native country.
They brought only their hopes, dreams, and enormous resolve and motivation for a
better life for themselves and their children. By their example, they imprinted in my
mind the importance of finding dignity and self–esteem through the pursuit of a worthy
cause, doing the right things, and sheer hard work and dedication.

I have the good fortune of having many friends, including many of the past Whitney
Award recipients. There are some individuals, however, who have been especially
instrumental in my personal journey: Henry Palmer, Doug Hepler, Herman Lazarus,
and John Webb, who helped me dust myself off and get up again at an early and
formative point in my career. Friends, residents, and students, at the University of
Connecticut Health Center and the Medical College of Virginia Hospitals, who helped
forge a new practice destiny in those hospitals. Donald Rucker of Chicago and Alex
Berman of Cincinnati, who continue to be wonderful friends and have inspired me in
countless ways.

In my present position, I’m blessed with a superb professional, technical, and support
staff, especially my professional partner and associate, Jim Hethcox, and our
entire department’s management team. I am also thankful for the support of the chairman
of the department of medicine, Dr. Stuart Levin; the vice president of medical
affairs and dean of Rush Medical College, Dr. Eric Brueschke; and the hospital administration.


Any references cited in this lecture are available in the PDF version.

Originally published in Am J Health-Syst Pharm. 1995; 52: 1763-70.
© 1995, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.