To Whom Much Is Given
In St. Paul’s Cathedral in London, a simple slab marks the tomb of its architect, Sir Christopher Wren. The inscription reads: “If you seek a memorial to this man, gaze about you.” It was not my privilege to have known Harvey Whitney during his lifetime, but it would be hard to imagine hospital pharmacy today without his inspiration, his influence on the practice of pharmacy in hospitals, on the birth of our professional Society, and on the many leaders and practitioners in hospital pharmacy whose professional lives were touched by Harvey Whitney. “If you seek a Whitney memorial, gaze about you.”
Some of those who preceded me in the honor you are bestowing tonight – in memory of Mr. Whitney – knew him well. It is heartwarming indeed to be included with those distinguished hospital pharmacists who previously have had the privilege of addressing you on this occasion.
I am deeply grateful to the Michigan Society of Hospital Pharmacists for selecting me for this honor and to the many hospital pharmacists and others throughout this nation who helped me to merit your recognition.
The title I have chosen is only half of the theme on which I have based this address: “To Whom Much Is Given.” The rest of it is: “Much More Will Be Required.”
As pharmacists, and more specifically as hospital pharmacists, what have we earned and been accorded? And because of these gains, how much more is required of us? Hospital pharmacists have earned professional recognition, the respect of co-professionals on the health care team, a needed status in the total hospital complex. You have the authority and responsibility for the management of a vital department within the hospital; for the professional selection, pharmaceutical evaluation, and proper dispensing of drugs. Your authority is a high trust. You have accepted and faithfully discharged a responsibility in the training and guidance of hospital pharmacists. For this accomplishment too, hospital pharmacy has been acclaimed; and because it has, even greater achievements and higher standards will be expected.
We often hear hospital pharmacy referred to as a vigorous, growing, young specialty. There can be no doubt of its vigor, of its growth, and that it is a specialty. But the historians tell us it really is not so young. Perhaps the first institutional pharmacy was practiced in the monasteries of the 13th or 14th century. Pharmacy in Egypt, Arabia, the Roman Empire, and other ancient civilizations antedates pharmacy in England, but there is a record of the employment of an apothecary in St. Bartholomew’s Hospital in London in 1572. Interestingly and familiarly enough, one of the problems of that day was finding a means of reducing the cost of drugs.
In America, the first hospital pharmacist was Jonathan Roberts, who served as apothecary in the Philadelphia Hospital until 1755 when he was succeeded by John Morgan. Another somewhat familiar story – Mr. Roberts left for a better paying job, and Mr. Morgan later left to study medicine.
Hospital pharmacy in military and government hospitals has closely paralleled that of civilian hospitals. During the Revolutionary War, Andrew Craigie was appointed as the first Apothecary General in the “Army of the Patriots” under General George Washington. It was his duty, and that of the apothecaries under him, to procure and dispense medicines for the army hospitals. This was a position of high rank and prestige, which later appears to have declined until military pharmacy again began its upward movement in this generation, as did pharmacy in civilian hospitals. Among the first medical care institutions for war veterans were the National Homes for Disabled Volunteer Soldiers established following the Civil War period – eight of them from 1866 through the latter part of the 19th century – today remaining, with new buildings and facilities, as parts of modern Veterans Administration hospitals. Although little has been recorded about their first pharmacists, it is known that early in the establishment of Veterans Administration medical care facilities pharmacies were provided for and operated by qualified pharmacists. A “Chief Druggist” was provided for in these facilities in 1881. As in civilian and military hospitals, pharmacists in the Veterans Administration were classified in a “subprofessional” category until the “rebirth” of all of hospital pharmacy in the forties when they were given full professional status.
Pharmacy historian Alex Berman describes the “awakening” of hospital pharmacy
in the twenties and its advance in the thirties in his discussion of the formative period of hospital pharmacy. You know well the events leading to the founding of the American Society of Hospital Pharmacists in the forties and of the leaders – their plans, hopes, disappointments, and successes. But to appreciate the advancement and development of hospital pharmacy practice as we know it today, I took a look back to see what hospital pharmacists were doing professionally in Harvey Whitney’s time – what they were talking about and what was thought of them.
I still enjoy reading the weekly newspaper from my hometown in Minnesota, although the most familiar names, I find after these many years, are in the “Harkening Back” column – a column of news events from 25 years ago. I wondered what a “harkening back” column of hospital pharmacy would show. It wasn’t hard to find out, because hospital pharmacists then, as now, were professional-minded, dedicated, and articulate individuals, though perhaps not at that time accorded the stature and professional prestige of our present-day practitioners. Thus, their writings in hospital literature were readily available and revealing.
In our “harkening back” column of 25 years ago, we would find articles on sterilizing medicinal substances, about making medications more palatable, a description of a plan for training pharmacy interns, of the conversion of two basement rooms of a hospital to a new pharmacy. One pharmacist-author wrote:
Cooperation between the pharmacist and the medical staff of the hospital is of vital importance . . . and: The pharmacist must be considered a vital part of the modern hospital and should be consulted by the different members of the staff when the occasion requires. Only in this way will the patient receive the utmost in medication and the hospital the ultimate in economy.
In addition to being a specialist, the pharmacist is a business and professional man. The administrator looks to him for help from a business standpoint, while the physicians and nurses look to him for professional help.
A commentary on hospital pharmacy education urged the addition of courses in X-ray and clinical laboratory techniques to the pharmacy curriculum to increase the pharmacist’s usefulness and employability, especially in smaller hospitals. With newer manufactured preparations available, pharmacists especially in tuberculosis, psychiatric, and smaller general hospitals would have more spare time, the writer said, and, furthermore, drugs were being supplemented by other forms of therapy such as light, heat, water, electricity, and exercise.
They could not have known at that time that we were on the brink of a breakthrough in drug therapy, which in the years immediately to follow would save and prolong the lives of thousands of tuberculosis patients, convert their hospital beds to other uses, and help to return many, many, previously hopeless mental patients to useful, meaningful lives in their communities; that would take the fear, the dread, and the tragedy out of many illnesses of only a generation ago. A breakthrough that would make drugs, and the pharmacies that dispense them, one of the most essential elements in all of hospital care. Hospital pharmacists were advised that the enterprising hospital pharmacist should be a member of the major hospital staff – attending conferences and participating in them; that he should be an important member of the nurses’ training school staff and, even more important, he should be the director, in his own way, of a certain postgraduate instruction to the intern corps.
That is our “harkening back” column. Harkening back to the days in which Harvey Whitney practiced and wielded his influence on those who were to follow and bring even greater recognition to hospital pharmacy and to make it more useful. Hospital pharmacy, even then, was on the move – restless, emerging, and getting set for more progress within the 20 years to come than the most optimistic would have predicted. But there were no more than 1000 pharmacists practicing in hospitals at that time – we probably have closer to 6000 today – and they had not achieved the professional stature of today’s highly regarded hospital pharmacists.
And now, two decades later, what are hospital pharmacists doing, what are they discussing, and what are their professional accomplishments? What is it that has elevated hospital pharmacists to this generation’s position of professional prestige and recognition? Summed up, it probably would be education, hard work, dedication, service above self. But for more specific explanations, look at the program for this Annual Meeting. Note the subject material in the four annual institutes on hospital pharmacy, now sponsored by the ASHP. Look at the Minimum Standard for Pharmacies in Hospitals; look at the recommended standards for residencies in hospital pharmacy.
If a profession can be judged by its literature, look at the subject material in the American Journal of Hospital Pharmacy. I took note of a few from recent issues: “Allergenic Prescriptions”; “Adverse Drug Reactions”; “Clinical Testing of Drugs”; “Tests for Identification of Drugs”; “Incompatibilities of Parenteral Products”; “Refractometry in Quality Control”; “Pharmacy Staffing and Workloads”; “Detecting Medication Errors” – the latter a field, incidentally, in which hospital pharmacy has pioneered in cooperative efforts with other professions, an example of assuming responsibility with patient safety and well being as the sole objective. Most of these articles were written by hospital pharmacy practitioners. I know of no other field of pharmacy practice, other than in pure research, in which the contributions to the professional literature are so voluminous or useful.
Hospital pharmacists and pharmacy educators have been working together the past three years in constructive efforts to improve the education of pharmacists for hospital pharmacy practice. To assure this, the abilities required of hospital pharmacists have been analyzed and summarized. A look at these abilities – found in today’s practicing hospital pharmacists – offers another clue to the reason for their position in the profession. You as a hospital pharmacist, if you head your department, must be a manager. Your responsibilities include program planning and integration with other hospital departments, interpretation of trends, budgeting, inventory control, personnel administration, and general administration of the pharmacy in a business-like way.
You have a thorough knowledge of drugs and their pharmacologic actions. You know the pharmaceutical properties of drugs and can judge their quality. You must be able to develop special product formulations and to manufacture in bulk quantities. You must understand and apply quality controls. The hospital pharmacist performs pharmaceutical research of an applied nature and develops new or improved products, and he participates in medical research. He teaches both pharmacy students and residents and pharmacy-related subjects to students and practitioners in other disciplines.
Hospital pharmacists also are looking to the future. Serious consideration is being given newer techniques and methods involving automation – not with misgivings and fear of change but with hope and expectation of even better things to come. They share with interest and enthusiasm the previews given us of the fast approaching future use in hospital pharmacy of automated data processing and other electronic aids. They know that the successful, progressive pharmacists of the future will be those who not only accept the changes made possible by newer methods but who find more ways of applying their knowledge and skills to improve ways of doing things more effectively and efficiently. Hospital pharmacy will not be the champion of the status quo. This is not unlike the acceptance of prefabricated pharmaceuticals, in contrast to the handmade ones of a few decades ago, which, while decreasing the demand for compounding services in some instances, has made drug therapy and pharmacy itself better, more efficient, and more accurate than ever before. And this change has by no means decreased the need for the education and knowledge of the pharmacist. On the contrary, he needs more knowledge, more education, to be applied in more useful ways now that less of his time is taken up with the technical chores of hand-fabricating medications.
Some pharmacists have concerned themselves a great deal recently with the “image” of pharmacy, with what the public thinks of our profession, of the way it is practiced, and what is thought of us as practitioners. Perhaps the truest of all “images” can be found in a mirror. It can only reflect what actually is there – no more, no less. It cannot flatter, and seldom can it misrepresent. A photograph, of course, also is an image and can be retouched to bring out the most favorable points in its subject. But the lasting impression is made by the subject itself – not by what the expert “retoucher” puts into the image. So it is with pharmacy. We may seek the advice of experts on how to put it in its best light, but the true image in the long run can only reflect what actually is there.
No public relations headlines are needed to establish the professional status of hospital pharmacy. No legislative acts or administrative decrees are needed to declare hospital pharmacy a profession. This you already have. Let us be sure in accepting this status, in accepting authority and responsibility, in accepting the respect of our associates and plaudits of the public, that we have actually earned them – and in return are providing even more in service and professional excellence.
I am convinced that one of the essential characteristics of pharmacy in our relation with the public is genuineness. Let the professional achievements of pharmacy practice be the reason for its existence, not merely one of its status symbols. If this is so, the “image” will take care of itself.
Much is said about the pharmacist in his role as an expert on drugs – as an authority on the pharmaceutical and therapeutic properties of drugs and their usage and dosage. Then let us be the “genuine” experts on drugs. Let us not be merely drug label readers or quoters of product package inserts. If we are to be experts on the properties of drugs, let us be experts in depth. If yours is the authority and responsibility for selecting the maker or source of supply for the drugs you dispense, accept that responsibility but be sure it is carried out well. If a physician prescribes a drug by a nonproprietary name without specifying a brand, he confers on you an authority and responsibility to apply your knowledge in selecting a product of the highest quality, effectiveness, and assured safety. This is a trust which hospital pharmacists strive for and are accorded more than in any other specialty of our profession. Guard it well.
Let us never go to the lawmakers for economic advantages under the guise of “protection” of the public health. If these are needed, let the reasons for them be genuine. Let us not jeopardize the elite, highly respected status of our Boards of Pharmacy by asking them to include “trade” control along with their vital responsibility for professional regulation. Pharmacy cannot afford to be found shallow and wanting in any of its claims when there is so much on the positive side to enhance its professional position. We live in a sophisticated society. It is true that pharmacists are university educated and that ours is a learned profession. But so are many others with whom we have daily associations – our patrons, colleagues, and the patients we serve – and many of them also belong to learned professions. No longer is the label of an educated person applied to a select few professionals in the community. We are not likely to convince many with exaggerated claims of professionalism if it is not a reality. But at the same time, our educated, sophisticated society, I am confident, is willing to accept, albeit take for granted, professional status wherever it genuinely exists. I am convinced that long after the derogatory headlines have been forgotten, many more of our people are going to be grateful for the health-giving, lifesaving drugs developed by the scientists of pharmacy than were swayed by the economic charges during the tempest of the past two years in Washington.
I am convinced that long after the headlines are forgotten, more people are going to have reason to be grateful for the effectiveness of our food and drug laws and the way in which they have been enforced for the protection of the public than were frightened by the publicity and drama during this period of strengthening and improving them.
I recently read an editorial in a small town weekly newspaper praising the community pharmacy – the only one in town – and urging its support on the basis of the need for it in that community in time of sickness and for the town’s other health care needs. This theme appealed to me particularly because I happen to have grown up in that pharmacy as a boy, but I believe this sentiment is typical of the feeling about pharmacies throughout this country, though not often expressed. I am convinced that long after the criticisms about prescription pricing and merchandising practices are forgotten, the good people of that community are going to be grateful for the assurance they get from having that pharmacy down on Main Street.
I am convinced that long after our current discussions of formulary systems, outpatient prescriptions, and the many other problems with which we now are concerned – long after these have been resolved – hospital patients and their physicians will be grateful for the hospital pharmacy and the hospital pharmacist in his essential role on the professional team.
One of the more serious responsibilities of hospital pharmacists, when they are given the opportunity, is the teaching and training of future practitioners. Professional training has been one of the responsibilities accepted by many pharmacists from the time our profession began. Probably it is because of its origin, because of tradition, and because few other centers of pharmacy practice were available that most preregistration internships have been served in community pharmacies. But is this still necessary, or adequate? More recently, we have seen the development of internships, now coming to be called residencies, in hospital pharmacy. Harvey Whitney was one of the early leaders in establishing hospital pharmacy internships. These are not intended primarily to qualify the intern for registration but rather to prepare him more thoroughly for the practice of pharmacy in hospitals. The American Society of Hospital Pharmacists has established high standards for hospital pharmacy internships (residencies), and a program for formal accreditation by the Society is now becoming a reality. Hospital pharmacy internships and residencies meeting ASHP standards offer exceptionally well-rounded training in professional pharmacy practice. In most states, this properly is accepted in fulfillment of the internship or “practical experience” requirement for registration.
In my view, another forward step in the training of all future practitioners of pharmacy would be the encouragement of a period of internship in a hospital, regardless of the type of practice the new graduate intends to go into after its completion. In this regard, perhaps we could draw an analogy with medicine. Internships in preparation for the practice of medicine are taken in hospitals. I am sure that many medical students and interns plan to practice in private offices or in group clinics. But regardless of this, the internship is taken in the hospital where the number of patients, the complexity of medical cases, and the variety of diseases provide the greatest opportunity for learning in the constant, concentrated, day-to-day treating of the sick and injured. Here the professional demands on the practitioner are the very greatest. The same could apply to pharmacy. What better training for the application of professional pharmacy in any setting than a period of internship furnishing pharmacy services all day, every day, to those sick enough to be hospitalized. In addition to its value as professional training, a period of internship in a hospital for all pharmacists would prepare them, as future community practitioners, for assuming a professional role in the hospitals and nursing homes of their communities, should the occasion arise.
The medical practice of most physicians is carried on both inside and outside the hospital. There is no reason why this dual area of service should not be followed by many pharmacists. Hospital pharmacists have long encouraged practitioners in community pharmacies to provide their services in hospitals in which there is not and perhaps, for economic reasons, cannot be a full-time hospital pharmacist. Some are doing this. But with the more than 3500 smaller hospitals in this country, and the number growing each year, without professional pharmacy services, there would appear to be little reason why a part of each day in the community hospital should not be a normal way of life for many community pharmacists.
In a special message to Congress this February, President Kennedy said:
Perhaps the most threatening breach in our health defenses is the shortage of trained health manpower.
He also said:
Although some progress has been made in meeting the backlog of need for chronic disease hospitals and nursing homes, it is estimated that less than one third of this need has been met and that an additional 500,000 beds for long term patients are required to meet today’s demand.
If these facilities the President said we need are to be provided, and indications are that they will be, tremendous increases in drug dispensing will follow, and this is going to require pharmacy services. Where are the pharmacists coming from? Some, no doubt, will be full-time hospital pharmacists. But in many cases, the opportunity and the need for community pharmacists to provide their services will be there. Pessimists in pharmacy have seen the times in which we live as the “beginning of the end” of pharmacy as a profession. Hospital pharmacy is proving this is not so – that we have just reached the “end of the beginning.”
Why has hospital pharmacy so rapidly gained the professional position it now enjoys? Deno, Brodie, and Rowe in their book The Profession of Pharmacy explained it this way:
The combination of right times, right leaders, and right organizations has given hospital pharmacy an opportunity for rapid growth unequalled in any other branch of the profession.
I believe it also is because hospital pharmacists, under the forward thrust of modern medicine, were given a challenge to provide higher level professional services. You accepted and met that challenge, and in so doing earned your present enviable place on the health sciences team. You have made the most of your opportunities and, as the servant in the parable, having been given five talents, invested them wisely and returned 10; and the one given two returned four; not as the third servant, given one talent, hid it and returned only the one, for he had been afraid of losing the one he had. You had confidence in your capabilities and the courage of H. A. K. Whitney. The evidence of the achievements of hospital pharmacy and the challenge of even greater ones are all about you.
We have been given much. But much more must be given in return.
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Hosp Pharm. 1963; 20:314-20.
© 1963, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.