Harvey A.K. Whitney Award Lectures

Searching for the Soul of Pharmacy

I invite you to join me this evening for a brief journey. Our destination will be an enhanced understanding of pharmacy as a health occupation. To reach that goal, we will walk to a few vantage points where the line of sight is just right to

see some unique facets of our field.

I made two assumptions in mapping our itinerary: first, that everyone here knows the fundamental, largely unrealized, value of pharmacists. And second, that everyone here believes a vital societal purpose is served by preserving and improving our discipline as a personal health service. If my assumptions had been different, I would have chosen another path.

I have billed this excursion as “Searching for the Soul of Pharmacy,” which is a metaphor for the task of professionalizing our calling. Thomas Moore, writing in Care of the Soul, explains:

“Soul” is not a thing, but a quality or a dimension of experiencing life and ourselves. It has to do with depth, value, relatedness, heart, and personal substance. I do not use the word here as an object of religious belief or as something to do with immortality.(1)

I am using the metaphor of soul because I believe that pharmacy cannot become a complete profession unless its practitioners have, in the words of Moore:

depth, value, relatedness, heart, and personal substance.

The nature of our discipline is the sum total of the inner drives—that is, the souls— of individual practitioners.

Reflect for a moment on the great social ills that plague our times: homelessness, drug abuse, domestic violence, children dying from gunshot wounds; the list goes on. As Daniel Patrick Moynihan has pointed out, we have reset the social norms so that atrocities such as drive-by shootings no longer evoke a sense of outrage.(2) How should our nation address intractable social problems? Solutions that have any hope of succeeding will aim at the hearts and minds of the people.

And thus it is in pharmacy. If reshaping the profession is the goal, then the target for action must be the souls of individual practitioners.

Out with the old, in with the new

Let’s begin our trip. The first vantage point offers a look at the health care enterprise.

No matter in which direction we glance, we see a preoccupation with consolidation and reconfiguration, justified by the need to lower costs. On a macro level, the major targets are excess hospital capacity and overuse of medical specialists. On a micro level, the focus is on the process of delivering care, which had become too skewed toward the convenience of providers at the expense of patients.

The experts say that health system integration will proceed until most communities have no more than three or so sources of health care. They assure us that all of the cost cutting is a necessary interim phase until the paradise of outcomes management is attained. And, we are reminded, this is private-sector health care reform, and that is good.

Congress abandoned national health reform in 1994 in part because the public feared that a new, giant bureaucracy would be created. It is ironic that what we are getting now are swelling health care networks that are often as rigid and impersonal as any invention of government.

Private-sector reform and for-profit managed care are polite terms for the rape of the health care system that had evolved after World War II. Undeniably, that system had many problems that begged to be fixed. Private insurance payment of charges and Medicare reimbursement of costs stimulated the mushrooming of specialization and the overuse of costly equipment and facilities. Health care financing carried a large overhead, which covered, in effect, public goods such as health professional education, research, public health, and uncompensated care.

But departure from the old does not in itself bestow virtue on the new. There is a distinct possibility that future social historians will characterize the current course of health care as excessive folly motivated by power and greed and unguided by a moral compass.

Smart financial people have figured out how to make big money during the transition to a new order. Profits and stock prices of health care companies have soared. Some health care executives are rewarded with annual compensation in the tens of millions of dollars. Even among nonprofit health systems, reserves in the billions of dollars have been accumulated. Health care consultants, who are absolutely brilliant at recommending solutions that lead to more business for themselves, are flourishing. In the face of all this plunder, the quality of patient care has frequently declined, but the overall cost of health care has not.

Moreover, the nation seems to be in a state of denial about the people who lack access to basic health care services. Yet the problems of the uninsured and the under-insured simply cannot be solved by the private sector alone. The only possible solution lies in a society-wide response that entails at least some role for state and national government. Hubert Humphrey said that a nation will be judged by how it treats the disadvantaged within its borders. He was right, and we can do better.

Recently, I have come to appreciate the thinking of Wendell Berry, a remarkable contemporary writer of essays, poetry, and fiction. His social criticism has renewed my awareness of the deep currents of life in our times.

Berry lives on a farm in his native Kentucky. Many of his ruminations deal with how national and international corporations and the technology they spawn are destroying communities such as his. Berry elucidates the natural connection between all life and the land. He explains how interference with that bond, in the interest of amassing corporate power and wealth, debases the lives of ordinary people. I had often thought that this analytical framework could be applied to modern health care, so I was pleased to discover a recent essay of his that makes this point explicit.

Listen to this comment by Berry:

How can cheapness be included in the criteria of medical . . . performance? And why has it not been included before now? I believe that the problem here is . . . the medical industry’s fixation on specialization, technology, and chemistry. As a result, the modern “health care system” has become a way of marketing industrial products, exactly like modern agriculture, impoverishing those who pay and enriching those who are paid. It is, in other words, an industry such as industries have always been.(3)

Corporatization of health care is indeed one of the dominant realities of our times. Steadily, the imperative to make a big profit is elbowing aside professional prerogatives throughout patient care. And, in the process, all health professionals are struggling to remain centered on the needs of patients.

Let’s think about these observations as they relate to pharmacy. Pharmacists in all sectors of practice are enmeshed in the web of health care transformation. In hospitals and health systems, this often results in a level of chaos that makes it difficult to concentrate on serving patients. Sometimes, amid this disorder, the only apparent plan for avoiding drug misadventures is for all health care workers to keep their fingers crossed. In health systems, many excellent pharmacy programs, which served patients well and built practitioner self-respect, have been dismantled.

Unfortunately, most health care settings do not have the benefit of sensitive executives who understand how to manage transitions well—who know how to lead a group wisely from letting go of the past, through the neutral zone between the old reality and the new, to the new beginning.(4) This insensitivity contributes to widespread anxiety among pharmacists about the future.

On the other hand, this era of re-creation in health care offers many opportunities for pharmacists who are enterprising and nimble. By and large, pharmacy’s leadership reflects the optimism of those who understand these opportunities. At times, it seems that the happiest pharmacists on earth are those who understand the flux of health care, who have a gift for sharing their insight, and who are excited by the race to stay at the forefront of change.

I worry, though, that many of these pharmacists seem to have turned themselves over completely to a corporate agenda, which generally has an antiquated view, or no view at all, of what pharmacists can contribute to patient care. To the extent that our best and brightest practice managers are absorbed by the business of health care, a vital thread in pharmacy’s soul is being unraveled.

Living, as we do, in a roiling brew of chaos and opportunity, we need to discipline ourselves at times to withdraw and look to the inner self. We may then see that the seductiveness of the new threatens to blind us to our primary obligations to the welfare and safety of patients. We may then see the pain of fellow travelers and reach out to them with a supportive hand. We may even detect in ourselves and our colleagues a moment of doubt about the wisdom of our course, which may in turn give us the courage to challenge small lunacies in our corner of the world. If practitioners do these things, they will be building their depth, value, relatedness, heart, and personal substance. They will be strengthening the soul of pharmacy.

Madison Avenue and the pharmacist

The next stop on our journey will be a short one. We will pause at a spot that offers a perspective on some aspects of the marketing of drug products.

Most of us became pharmacists during an era when the primary marketing target of the industry was the physician. Convince the doctor to prescribe a product, and the battle was won. Now the target is shifting. It is becoming the consumer.

Hence, we are seeing a tremendous upsurge in direct-to-consumer advertising of prescription drug products, the creation of over-the-counter versions of prescription medicines, industry funding of patient advocacy groups, drug company sponsorship of behavior modification programs designed to increase patient compliance, and the construction of disease-specific patient databases that permit a company to write or call individuals who have an illness that corresponds to its product line.

This marketing shift is part of a broader attempt by the industry to control all steps in the process from discovery of a drug to its consumption by the consumer. Manifestations of this goal include restricted product-distribution schemes, disease management programs, and diversification into pharmacy benefit management, mail-order pharmacy, and specialized health care services.

Implicit in the push for consumer-focused marketing is the idea that advertising and labeling can cover everything a person needs to know about a drug product. This is quite contrary to the scientific knowledge, experience, and beliefs of pharmacists. Somehow, practicing pharmacists must position themselves as a buffer between Madison Avenue and the patient. This is already being done by health-system pharmacists who are involved in developing drug-use policy. But the role of the frontline practitioner as a counterbalance to drug hucksterism is largely undefined.

There are no overt incentives for practicing pharmacists and their organizations to cry out the truth about the need for caution and skepticism in all medication use. The motivation for doing so must come from keen thinking about the subtleties of drug marketing and their implications for public health. If pharmacists are passive about drug company manipulation of consumer medication practices, then any search for the soul of pharmacy will become irrelevant.

Pharmacist allegiance

We will move now to the final stop in our stroll, which will give us a look at pharmacy practice itself.

The most truthful thing I can say about pharmacy practice is this: It is an occupation psychically bound to the act of providing medications to patients, but which knows that it must find a new reason for being.

There is hope in pharmacy’s recognition that it must change. And there is hope in the fact that many pharmacists have rallied around pharmaceutical care, which has a strong moral and philosophical foundation. But there is no guarantee that this hope will lead, anytime soon, to a secure place in health care.

Let me tell you a story about Jonas Salk. Dr. Salk was the University of Pittsburgh virologist who developed the first safe and effective polio vaccine, and he was widely admired for that achievement. He used to deflect public adulation by referring to a Harvard scientist, John F. Enders, and saying of him:

He threw a long forward pass, and I caught it.

It was Enders who had developed the method of culturing polioviruses that made Salk’s achievement possible. Enders threw a long forward pass and Salk caught it.

The history of pharmacy records some long forward passes but also documents many fumbles and incompletes. In particular, what come to mind are this century’s numerous efforts(5 )to marshal support for fundamental reforms of pharmacy practice and education based on systematic studies of the field. To be sure, these efforts influenced the upgrading of pharmacy education from a two-year minimum requirement in 1907 to five years in 1960. But, unlike medicine,(6) pharmacy has never found the resources or the resolve to sustain for long any well-organized, precisely targeted reform that made a difference in the status of the occupation.

The heritage of pharmacy is a motley mix of business and practitioner interests. For a long time now, the majority of practicing pharmacists have been employees, not pharmacy owners. But the practitioner community has made very little progress in articulating its unique interests as a health occupation—interests that are quite different from those of the business, institutional, or corporate entities that employ pharmacists.

Practitioner organizations should be dauntless in making this distinction to public policy makers and to the standard-setting bodies in practice and education. The essential difference between the pharmacist and the pharmacy facility should be reinforced whenever a health consumer and a practitioner interact. It should be crystal clear in those encounters that the pharmacist has no allegiance greater than that to the individual being served.

Those instances in which patients actually see pharmacists occur mostly in drugstores. There the pharmacists are, sometimes on a platform, sometimes behind glass, busy, isolated, in their sanctuaries. But at least they can be spotted. That is more than generally can be said for pharmacists in hospitals.

The law of the land says that pharmacists must offer to talk to ambulatory patients about their prescription medications. What a priceless opportunity for the pharmacist to demonstrate a responsibility to the patient, and to reinforce that fidelity again and again. It was a dark hour for pharmacy when, in an apparent telepathic wave of groupthink, the owners and managers of community pharmacies decided to obey merely the letter of the law, not its spirit. At prescription counters across the nation, clerks are asking customers, “You don’t really want to bother a pharmacist with questions about your medicines, do you? Then please sign here so we won’t get into trouble with the law.”

Although the importance of this issue is self-evident, there is little fervor among pharmacists anywhere for changing the practice. But unless pharmacists begin showing their souls at the prescription counter and the outpatient window, pharmacy will be haunted to its grave by this missed opportunity.

Let’s shift our sight for a moment to acute care pharmacy practice. Rampant lip service is given here to pharmaceutical care. Yet the concept has been very difficult for hospital pharmacists to implement because it calls for a direct relationship with the patient. This characteristic of pharmaceutical care encounters five major barriers in hospitals.

First, in the hospital, patients clearly “belong” to the attending physician. There is not a tradition in hospitals of nonphysicians consulting independently with the patient.

Second, in the culture of hospital pharmacy, the practitioner is oriented toward the hospital and its rules, not toward the personal health needs of the patient. In other words, the pharmacist’s covenant has been with the hospital, not the patient.

Third, clinical pharmacy, as it evolved in hospitals, has been oriented toward the physician, not the patient directly. Here the pharmacist’s covenant is with the doctor.

Fourth, the reward system in hospital pharmacy for so long has been tied to efficiency and accuracy in drug distribution that pharmacists have been much too slow to turn over this work to well-trained technicians.

Fifth, hospital pharmacy still suffers from a vestige of an earlier age when it attracted practitioners who wanted refuge from the patient contact of community pharmacy. Unfortunately for us today, there is no tradition in hospitals of pharmacists talking with patients. Even when pharmacists accompany physicians on rounds, they are often there incognito, under cover as just another medical consultant. Most hospitalized patients have absolutely no awareness of how pharmacists are contributing to their care.

This analysis can be boiled down to the fact that hospital pharmacists, including clinical practitioners, have defined their roles primarily in terms of technical competence, not in terms of patient care. This is not a patina that can be rubbed away lightly; it emanates from deep within hospital pharmacists. For that reason, I think we have greatly underestimated the magnitude of the paradigm shift that pharmaceutical care embodies. This concept of practice poses as great a leap for hospital pharmacy as the shift in the world of astronomy from Ptolemy to Copernicus, or in the field of physics from Newton to Einstein. It will take much more time and effort to transform acute care pharmacy practice in the direction of pharmaceutical care than most of us have imagined.

Nourishing the soul of pharmacy

I willingly concede that for every case of disappointment I have cited, just as many hopeful examples about the vitality of pharmacy can readily be found. By no means is everything doom and gloom in pharmacy practice. But I had four reasons for leading you down the particular path I chose.

First, I believe that we tend to deny the true state of pharmacy practice.

Second, I believe that denial is not a sound basis on which to build our future.

Third, I believe that the fate of pharmacy practice in all settings is interlinked, and that specialized areas should not isolate themselves from the discipline as a whole.

Fourth, I believe that we need to work on nourishing the soul of pharmacy, as reflected in the orientation of individual practitioners, if we are to save this occupation for the benefit of patients.

How do we nourish the soul of pharmacy? I do not profess to have the answer to that question. But let me suggest several ideas that may be worthy of consideration:

1. Encourage ambulatory patients to select a personal pharmacist. Not
   a pharmacy, but a pharmacist.
2. Teach pharmacists how to recognize and resist corporate edicts, both
   blatant and subtle, that undermine their ability to care for patients.
3. Recognize and honor pharmacists who have demonstrated an
   authentic professional commitment to patients. We need more
   heroes in the frontline ranks of pharmacy.
4. Increase efforts to develop and enrich the work of frontline pharmacists in all practice settings. Let’s not become distracted from the fact
   that the true nature of our discipline is defined in the everyday interface between pharmacists and patients.
5. Limit entry to colleges of pharmacy to students who have already demonstrated their capacity for compassion and caring.
6. Develop a public report card on colleges of pharmacy and postgraduate residency programs that rates their ability to produce
   outstanding patient care pharmacists.
7. Foster a nationwide dialogue among pharmacists and physicians and
   consumer representatives about the problems related to medication
   use and what these three groups can do together to make the situation better.
8. Systematically focus the immense but fragmented continuing-education resources of pharmacy on the knowledge and skills that
   will be needed by practitioners to make our discipline a caring
   profession.
9. Create a high-profile center supported by pharmacists and consumers to study societal medication-use issues and make recommendations for resolving them. Include in the scope of this center the
   effects of industry marketing practices.
10. Put as much energy into long-term planning for pharmacy as is put
    into short-term strategizing. Let’s begin to outline, through our
    professional organizations, what we can achieve over a generation or
    two, not just within the next 12 months. Let’s see if we can coordinate the planning efforts of national and state practitioner organizations and the academic community.

Conclusion

In drawing this journey to a close, let me remind you of Thomas Moore’s definition of soul:

It has to do with depth, value, relatedness, heart, and personal substance.

People want and need pharmacists with those characteristics—pharmacists with soul.

Let’s dedicate ourselves to remaking this occupation of ours into a profession that gives people what they want and need.

This is not an agenda that we can assign to someone else. Each of us must take personal responsibility for making this happen.

Individually, we can examine and adjust the focus of our own work. We can support and encourage our colleagues in the same pursuit. We can create and support collectively, through our professional organizations, long-term efforts that build the soul of pharmacy.

Above all, we can speak up.

Speak up for the patient.
Speak up for safe medication-handling practices.
Speak up for medication therapy that makes sense.
We can do this.
We must do this.

***

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

Originally published in Am J Health-Syst Pharm. 1996; 53: 1911-6.
© 1996, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.