For more than two decades we have focused our attention on the development, implementation, and evaluation of pharmaceutical care practice. Indeed, as we look back and contemplate those formative years and the struggle to create a new practice, we realize that no matter how serious the debates, no matter how much resistance to change was encountered, this was a productive period, which profoundly influenced the development and direction of a profession. Our initial preoccupations focused on the prevailing realities of pharmacy as a profession grounded in what is often referred to as the real world.
In essence, we struggled to understand both the nature and dynamics of a profession that was clearly in need of serious critical analysis. We swiftly learned that professions, as organizational entities, do not take too kindly to criticism or even intellectual exchange no matter how positively or responsibly applied. The public face of profession very rapidly becomes personal, and the debate-of-the-day is recast in defensive posturing and political positioning that serve no progressive purpose whatsoever. Our observations that pharmacy, at least in the United States, was far too preoccupied with ‘product’ and too little committed to cognitive functions were generally seen as idealistic, unreal, or simply the wrongheaded notions of academics cloistered in colleges, detached from such practical matters as survival in the marketplace.
In the face of considerable opposition, at both the grass roots and organizational levels, we continued to assert that pharmacy must seriously begin to refocus and move in a direction that would establish more productive, expanded roles and responsibilities. We recognized the inherent tension that exists in pharmacy culture and the push and pull of the commercial and the clinical. Moreover, we observed that such tensions produced many conflicts of interest and ethical issues that contribute to inertia and resistance to change. We concluded that somehow a new direction was called for and that this was important enough to warrant significant time, energy, and effort to determine.
Starting a pharmaceutical care practice is a serious, full time undertaking. Patient recruitment, providing care, documenting care, improving clinical skills, obtaining reimbursement, expanding the practice, and establishing professional relationships are demanding but rewarding activities. However, the process itself is not complicated. In fact, every health care practitioner who has ever established a new practice physicians, nurses, dentists, and veterinarians follows the same process and organizes the practice around specific objectives and responsibilities. Numerous resources exist that introduce readers to the basics of practice development and implementation. All materials that focus on other health care professionals and their experiences developing practices can be extrapolated from and made to fit the exigencies of pharmaceutical care practitioners.
Over the past twenty-five years, Pharmacists and doctors have developed, and evaluated numerous approaches to pharmaceutical care. We have had many discussions and disputations on the subject of where it is appropriate to practice patient care. We have concluded that contrary to widespread received wisdom, it is extremely difficult, if not impossible, to provide pharmaceutical care to patients while dispensing medications in the retail setting. This is an important issue to reflect on because we continue to find many pharmacists who strongly believe that it can be done. Based on considerable evidence, we disagree. The provision of pharmaceutical care services is completely different in nature than the commercial retailing of a product. These two distinct interests have quite different priorities, rules, relationships, aspirations, and expectations, yet each demands the pharmacist’s complete attention. They are managed differently, rewarded differently, and require dissimilar values, skills, and knowledge. Therefore, there is a considerable divide between the two sets of objectives and responsibilities.
Perhaps the most frequent question we are asked is: “With which patient should I start?” Our unwavering response is “the next person who walks through the door.” Although this might sound somewhat facile, it is nevertheless the rule we follow. As practitioners we cannot ethically chose the patient with the “right” or most interesting disease, or the patient who would be happy to enrich us, or the patient who fits some predetermined selection criteria. Pharmaceutical care practitioners must provide care to all those in need, and not merely to those who meet the practitioner’s interests. Self-interest must be tempered with the recognition of the primacy of patient need and all that this entails.
This is quite a large commitment and a willingness to put the patient’s needs above all else is the essence of an ethical practice. Indeed, the test of an individual’s commitment to pharmaceutical care is found in the acceptance of such a serious responsibility. All individuals, including those who are presently taking medications, or need to take them, are included in the pharmacist’s clinical remit. There is certainly no lack of potential patients and no shortage of drug therapy problems waiting to be discovered. In effect, any individual who is willing to accept the offer of pharmaceutical care, or who asks for it, is a potential patient.
Moreover, we have found that a financially viable practice requires a patient base of 1200 to 2500 patients. Given this seemingly large number, it can be seen that the issue of recruitment, and informing the public of new services offered, is not to be taken lightly. A word of caution: do not overly concern yourself with the nature and type of your patient’s diseases or drugs. All of them are of interest to you and all of them can benefit from your knowledge and skills to resolve drug therapy problems.
In order to describe the impact that pharmaceutical care practice has on patients, we have conducted a review of the electronic records of adult patients who received pharmaceutical care over a four year period from 36 practitioners who completed the training program described earlier, and who documented the care provided using the Assurance Pharmaceutical Care system. All adult patients who had an initial assessment and a minimum of one follow-up evaluation were included for this manuscript. Most of our practitioners provided care for patients in collaboration with family practice, general internal medicine, or other adult medical practitioners. For our purposes here, we did not include the records of a relatively small number of younger patients as we have not accumulated sufficient experience with this group to determine the impact of pharmaceutical care. It should be noted that the results reported here are not from a specific research project, but reflect data generated directly from practice.
Evaluating Patient Outcomes In order to analyze the clinical impact of any drug therapy, practitioners must document several components of the patient’s care. The impact on each patient must be considered separately. The medical condition must be documented in a standard format. Each drug therapy must be associated with a clinical indication at the time of the assessment. Goals of therapy must be established for each condition being managed with drug therapy. Drug therapy problems identified are documented and include the drug therapy involved, the primary cause of the problem, and the medical condition affected. At each follow-up evaluation, the status of the medical condition being treated is compared to the desired goals of therapy and is documented. All of these components of pharmacotherapy must be documented within an individual patient’s record in order to be able to determine outcomes of drug therapies or the clinical impact of pharmaceutical care services.
The Assurance Pharmaceutical Care system is a state of-the-art clinical documentation system providing the capability to document the change in clinical status of each patient’s medical condition resulting from drug therapy. For each patient, improvement or lack of improvement in each medical condition can be recorded at each pharmaceutical care encounter. The clinical status codes defined in our books serve as the basis for this unique, efficient method to analyze clinical outcomes for any patient being treated for any medical condition.
The training programs that we conducted did not include the formal teaching of pharmacology or pharmacotherapy. Conventional pharmacy education teaches abstract pharmacology usually far removed from patient care. We have found that participants find both pharmacology and pharmacotherapy more relevant and more meaningful when learned in relation to the realities of specific patients, their needs, and the act of caring for them. This general problem-based learning method has been used by us for more than twenty years, and we are convinced that it is the most effective way to prepare future providers of pharmaceutical care. The need for specific knowledge was identified through interaction with individual patients. Each patient became a learning experience during which the practitioner negotiated between patient needs and required knowledge
Pharmaceutical Care Practitioners Collaboration is vital. During the training sessions it became readily apparent that pharmacists tend to see themselves as independent professionals who simply “do their own thing”. That is to say they commonly work alone in a job, and depend upon themselves to complete the traditional activities of the dispensing pharmacist. Perhaps this is an occupational hazard resulting from predominantly technical performance and the under-utilization of knowledge and other skills. In any event, we have found that a strong individualism characterized the pharmacists in our training programs an individualism that seemed to legitimize any personal idiosyncratic approach to “practicing” pharmacy.
Interestingly, during the course of our travels we have encountered similar behavior in pharmacists throughout the world. We are of the opinion that this individualistic approach to “practicing” pharmacy must change. Pharmaceutical care cannot simply be characterized and performed by those who insist that whatever they personally do is appropriate and adequate to define the practice. Too often we encounter individuals who insist that they “do” pharmaceutical care when all evidence indicates that what they are doing is only a variation on a vague theme of counseling, pharmacokinetics, or therapeutic drug monitoring.
Patient care is face-to-face interaction with a complete and complex human being. We begin with the embodied individual at a macro-level with all of his or her diverse expressions of need. Pharmacists were taught to assess these drug-related needs from the perspective of each patient’s unique medication experience. The medication experience is a new concept in practice that we have recently defined as the sum of all events in a patient’s life that involve medication use. It includes the patient’s expectations, wants, concerns, preferences, attitudes, and beliefs, as well as the cultural, ethical, and religious influences on his/her medication taking behavior. In short, the patient’s medication experience is the context in which all drug therapy decisions are made in pharmaceutical care practice. This experience will have a profound effect on the decisions a patient makes everyday as to whether or not to take his/her medications and exactly how he/she will take them. It should be clear why the pharmaceutical care practitioner needs an in-depth understanding of each patient’s medication experience to have a positive impact on the patient’s decisions and experiences.
For over a quarter of a century, pharmaceutical care providers are committed being available to describe and develop the numerous components of their practice. This has been done by integrating procedures that develop a new patient care service.
These practice components include:
the application of a new practice philosophy to the patient care environment,
explicit description of practitioner responsibilities,
establishing drug therapy problem categories and their common causes,
Describing the Pharmacotherapy Workup,
Defining standard terminology to describe clinical outcomes from drug therapies,
Structuring an assessment,
Providing quality care plan and follow-up evaluation that focus on improving outcomes from drug therapies,
Defining professional standards and standards of care for pharmaceutical care practitioners,
Adapting a reimbursement structure compatible with existing health care payment systems,
Developing a computer program to document patient care and manage a new service,
Creating a training program for pharmacists that wanted to learn new skills
Analyzing and publishing practice-based data describing the clinical and economic impact of pharmaceutical care practice.
It is important to note that there is a very important role played by pharmaceutical service providers. Through their undying efforts, the world can now enjoy medical products which are made out of their knowledge and expertise.