Quo Vadis 20th Century Hospital Pharmacy?
It is a gratifying task to have this opportunity to review the Society’s history from the vantage point of time and to trace in studied retrospect the touchstones of its stable progress, prudent adaptations, and provident changes.
The position and status of pharmacy in its relation to hospitals are significantly interesting and enlightening. At the turn of this century, hospitals bore the stigma of being “houses of death” rather than havens of cure and recovery. Accrediting bodies were nonexistent. Medical science was but in its infancy. Hospital pharmacy found itself in the company of a sapling profession.
The community pharmacist–or “druggist” of that day–provided relief for minor ills without a doctor’s prescription since legal controls over medications were negligible. Prior to 1914, narcotics could be purchased over the counter with no ado. Possibly at this time the image of the community pharmacist fared somewhat better than that of the hospital. As the practice of medicine progressed and the uneventful recoveries of patients increased, the public’s reaction towards hospitals took on a tone of confidence and the “house of death” image gave way to the “temple of hope.” The very choice of the word “temple” presaged the growing respect which accompanied the discovery of successful new drugs and the introduction of Blue Cross and other insurance plans which militated towards the alleviation of financial stress. Doctors were regarded with unhesitating esteem, nurses and other personnel as “angels of mercy.”
This utopian concept was dimmed by materialism and selfishness, and hospitals lost their enchantment in the emerging third image, which categorized them with such facilities as public schools, parks, and libraries or gave them placement with mere utilities such as gas, electricity, and water. Hospitalization was no longer recognized as a privilege but demanded as a right. Its services were price tagged, it knew the worries of litigations; and to the less dedicated and scarcely inspired, it became a place to work rather than one in which to serve. And yet despite these disappointing and disillusioning ramifications, the hospital continues to occupy a unique place in society, for in God’s economy the foibles of human nature continue to be overshadowed by the dignity of man as the constant reflections of the divine in him mirror his changeless purpose in life and his intended majestic end.
Pharmacy was the first of the related medical professions to follow medicine in requiring registration by examination and the last to exact a hospital residency. All states except one require one year of practical experience for state board of pharmacy examination; this period often is loosely termed an internship but in most instances is wanting in caliber. (Mississippi requires only diploma registration for the practice of pharmacy.)
It is regrettable that most schools of pharmacy have lacked foresight in employing this formal educational associate to capacity, exhibiting a lamentable apathy in recognizing the urgency of upgrading the educational curriculum for hospital pharmacy in keeping with the steady advancement of its standards. We ask: “Is pharmacy now to assume the role of laggard where previously it merited the position of leader?” Colleges of pharmacy are not solely responsible for this plight. In general, hospitals must share the honest blame created by such diluting factors as unqualified personnel, insufficient knowledge, want of understanding, and lack of sympathetic rapport.
It gives me a warm happiness to point out, however, that St. Mary’s Infirmary, St. Louis, Missouri, predecessor of the present St. Mary’s Hospital and one of the 89 hospitals of the country and one of the two institutions in St. Louis, Missouri, approved in 1914 by the American College of Surgeons (now the Joint Commission on Accreditation of Hospitals), at that time enjoyed a stable superiority which has been transmitted to St. Mary’s Hospital and the other hospitals administered by the Sisters of St. Mary. This unique position is due to the spirit and traditions of the Sisters of St. Mary but particularly to the faith, courage, and broad vision of Mother Mary Concordia, our fourth Superior General, whose reputation as a woman of God and a leading hospital administrator is surpassed only by her rich legacies to posterity. She, together with Sister Mary Irene, S.S.M., and the Reverend Alphonse M. Schwitalla, S.J., brought to birth collegiate programs in the various paramedical professions which hitherto enjoyed only a practical status. She opened St. Mary’s Hospital to religious health care professionals from every congregation in the United States and Canada and other interested persons for advanced education in the various hospital specialties. She also provided hospital facilities for the St. Louis University School of Medicine, thus enabling it to meet its vital accreditation requisite.
Startling developments in pharmacy practice were in the offing as World War I made history; and when physicians returned home, their battle-scarred achievements included the administration of glucose intravenously. This scientific advancement horizoned the necessity of the well-organized bulk compounding departments we know today. Dextrose and other preparations for parenteral use were not on the market; the market had to be created by the demand. Force of circumstances prompted the preparation of these solutions with materials and equipment that would not be acceptable today. Nevertheless, the hospitals engaged in this service then were among the best in the nation and were accredited by the American College of Surgeons, the only accrediting body for hospitals at that time.
It is interesting to note the changing patterns of practice from nearly total compounding with inadequate equipment to almost total purchasing, occasioned by the changing patterns of physicians’ prescribing and of manufacturing firms’ production. Hospital pharmacists, cognizant of the poor caliber of their working equipment, resorted to purchasing many products. A little later, as pilot-sized equipment became available, these same hospital pharmacists again took up their rightful prerogative of bulk compounding. The gap created by varying trends of the immediate past was again closing so that hospital pharmacists were once more in a position to fulfill their essential duties of service and education.
While it is conceded that many of our hospitals, especially the smaller ones, find it impractical to establish bulk compounding departments, still it is essential that these facilities be provided by teaching and research institutions to ground pharmacy students in the professional techniques involved in this vital area of service since frequently every hospital pharmacist must apply these techniques for small- or single-dose preparations. While colleges of pharmacy generally offer limited courses of this nature, not all offer curricula in manufacturing scoped to accommodate the specific needs of hospital pharmacy. Today, we find that more teaching hospitals are utilizing the services of product-development specialists, assay and control specialists, and research specialists to work with the medical staff in developing and testing new drug products and preparations for patients.
In the early part of the century, few drugs gave prolonged relief and fewer cured anything. Reactions resulting from drug therapy were generally unrecognized and, consequently, unheeded since the existing relationship between the action of drugs and the chemical composition and physiological properties of the body had not as yet been discovered, probed, and proved.
Standardization measures, communication media, and scientific advancement saw themselves personified in formal attire as the American Society of Hospital Pharmacists in 1942. Its initial 152 organizers were designated as charter members. In the following year, it gained 265 new adherents who well deserve to be designated informally as “near-charter” members, helping as they did to lay the arduous groundwork of the Society’s foundation. Harvey A. K. Whitney was elected its first chairman, a position comparable to today’s president.
In Mr. Whitney’s initial message, “Getting Out of the Cellar,” he viewed the Society’s members as pioneers who, “like the early settlers devoted themselves to hacking, scratching, and building pathways through unchartered areas of the hills and swamps, overgrowth, undergrowth and other imposing obstacles.” All of these difficulties, he hastened to add, “should never be allowed to obscure the general direction we shall set toward the goal of professional respectability and secure a free way of living in the atmosphere of our chosen field of special endeavor.” One can’t help wishing that all hospital administrators and hospital pharmacists would have grasped the import of Mr. Whitney’s provocative message and that our vineyard would be teeming with a happy abundance of qualified workers.
An understanding of the progress of the Society from its beginnings may be observed by reviewing the Society’s publications, choice distillations all of the determination, courage, and convictions of hospital pharmacy pioneers whose luster shone in their simplicity, whose strength rested in their frail beginnings, whose wealth was their personal loyalty to the cause they served so well. In 1944, they passed a resolution stating: “The Finance Committee may without further action pass on all accounts or appropriations not exceeding $25.00.” Our present annual budget of approximately one-half million dollars evidences how they envisioned the oak while planting the acorn! Certainly, it is a warm satisfaction to every member of the Society to know that this budget is being applied constantly in bringing increased services and educational opportunities to its more than 4000 members. You must be more than pleased with the services provided, services which dedicated and tireless workers have blessed into significant educational and professional profits for the advancement of pharmacy and its pharmacists.
Were Mr. Whitney to return to earth today to roam the ground of hospital pharmacy, I believe he would know neither surprise nor frustration. Rather, I think the milestones of advancement of pharmacy would delight his heart and transfuse him with renewed positive restlessness for the Society’s continuing progress. Effortlessly, I think he would join forces with those “poets of the intellect” whose scientific research knows almost daily reward as the Lord of all creation blesses their tireless endeavors with miniature souvenirs of His omnipotence and omniscience. I like to think that this delicate courtesy of God is in recognition of His creatures’ eagerness to fulfill His command to subdue the earth and bring all things under subjection.
God’s benevolence towards mankind knows no respite, permitting Dr. John R. McGibony and like men of wisdom to dream on and on about miniaturization of modern facilities that will produce automatic bedside techniques for instant diagnosis; remote consultation through microcircuit television media; microwave cooking with floor vending machines; disposable or edible dishes; garbage disintegration; electric power through transmitters or small atomic energy units; walls and ceilings adapted to supply light; electronic prevention or removal of dust and dirt; blanket heating, cooling, and ventilating for entire communities rather than for individual units; entirely disposable linens; and transportation via moving corridors, sidewalks, and highways.
As the fantasy of these and other wonders give way to actuality, data processing eventually will score admittance throughout entire hospitals as pilot plants now apply themselves diligently to testing various systems and ascertaining economic modes of installation. Universities are teaching courses in electronics for application in hospital operations. A singularly fascinating device, described in the January 1, 1964, issue of Hospitals, points to error prevention in the administration of drugs. For example, should a request for a wrong dose or an incorrectly named drug be inserted into the machine, the device will immediately type back “this is an incorrect dose” or “there is no such drug; please check with the physician.” We know that the device can return only that information which has been stored in its memory. This information should be provided by the pharmacist. The inadequacy of my description should serve but to heighten your interest in scanning the entire article.
Pharmacywise, it is hoped that data processing will provide time for the pharmacist to function more fully in his professional capacity. Today, medications are being added to intravenous solutions during actual injection. It is essential that the person functioning in this capacity knows whether or not these drugs are chemically, physiologically, and pharmacologically compatible, for often they are not. Often, queries of just this nature are directed to the hospital pharmacy from various nursing divisions. The diminution of clerical duties should relieve the pharmacist to serve more adequately in his roles of consulting, teaching, and investigational research, especially in conjunction with the newly established drug information centers, and as the reporting center of the hospital for adverse drug reactions. This type of service is a new breakthrough towards progress – one that all hospital pharmacists should endeavor to establish. While it may seem that hospital pharmacists have practically always been the source of drug information, this new concept offers a far broader service and accommodating scope in its tremendous potential for better patient care. Data-processing equipment will be invaluable in this particular area, in fact almost indispensable as the program becomes fully developed.
This last-mentioned item has brought us to the very doorstep of the January 1965 issue of the American Journal of Hospital Pharmacy and the February 1965 issue of the Journal of the American Pharmaceutical Association. A soul-searching look of gratitude is directed to the past; a smile for work well done suffices for the present; a stable willingness of body, mind, and heart welcomes the future. And so long live hospital pharmacy! As we continue down the corridor of time and perform our life work in this field, let us be reminded that somehow we know that something of the awful sameness, kindness, and clearness of Providence will continue to shine through the reverses and successes that trample and temper as God seasons the raw matter of our efforts with His readying grace and halos seeming failures with divine unpredictability. Somehow, we know that often those who till most fervently and tirelessly reap but poorly. But smallness knows no entree in devoted, dedicated hearts. Garnered for posterity, the vintaged steadfastness of our pioneers has braved the chasmy gap of diffidence for those of us who often might falter still were it not for the timeless bridge which their love for mankind fashioned for all future hospital pharmacists worthy of the name.
In the convergence of human interests, as hospital pharmacy converges for us, no life is a purely private affair, and no one knows the numbers whom he has helped or hindered along life’s road. Our actions as echoes ring down the valleys of other lives like voices of distant bells, quietly and impartially reaching to the most secluded, almost forgotten hamlets of men. Our lives sweep through those of others like the wind over the waters of the sea, whose waves reach even unto distant shores. Our acts of kindness, an encouraging word, our courage to fight for better patient care through quality pharmaceutical services are seen and heard or noted, imitated, and, in turn, pattern happiness in the lives of others, give proper direction to future hospital pharmacists and aid to the sick and injured in our communities.
Again, I thank each one of you! May God always bless you for your goodness and your kindness to others!
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Hosp Pharm. 1965: 22: 363-5.
© 1965, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.