A Vision of Pharmacy's Future Roles, Responsibilities, and Manpower Needs in the United States

This paper was prepared by the 1997-1999 ACCP Clinical Practice Affairs Subcommittee A: Michael S. Maddux, PharmD, FCCP, Chair; Betty J. Dong, PharmD; William A. Miller, PharmD, FCCP; Kent M. Nelson, PharmD, BCPS; Marsha A. Raebel, PharmD, FCCP, BCPS; Cynthia L. Raehl, PharmD; and William E. Smith, PharmD, PhD

Pharmacotherapy. 2000;20(8) 

In This Article

Toward a Unified Philosophy of Practice

The pharmacist has lost his professional standing primarily because the patient cannot visualize him as a tradesman and a professional simultaneously.
The Dichter Report, 1973 [8]

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.
Zellmer, 1996 [9]

Thus, we see today a major proportion of pharmacists in both community and health-system settings who perform solely or primarily distributive functions, the uneven adoption since the 1970s of clinical tasks, and much talk about, but scant performance of, pharmaceutical care functions by either health-system or community pharmacists.
Holland and Nimmo, 1999 [10]

Throughout its modern history, pharmacy has struggled to balance the profession's seemingly dual mercantile and professional missions. The Dichter report, commissioned by the American Pharmaceutical Association (APhA) in 1972 to analyze consumers' perceptions of pharmacists, noted that this model of merchant-professional was in agreement with no other profession's credo and therefore was potentially dysfunctional.

[8]

Pharmacy is the only health care profession that is reimbursed primarily through sale of a product rather than for provision of patient-specific service.

[11]

The profession's movement toward patient-centered practice in the 1960s, 1970s, and 1980s resulted in promulgation of the principles of clinical pharmacy practice, drug information services, and eventually, pharmaceutical care.

[12]

In the early 1990s, the provision of pharmaceutical care was endorsed broadly by the profession, including pharmacy educators, as its new professional mission.

[13]

However, continued high demand for product-oriented practitioners, combined with the absence of viable reimbursement systems for nondistributive patient care services, made the implementation of patient-centered practice impractical for the profession as a whole...

until now.

Today, it is apparent that technology-driven, cost-effective systems for managing the drug distribution process are a reality, and these systems will be refined and widely implemented in the near future.[5] Technical support personnel are becoming more extensively deployed in pharmacies, and the involvement of pharmacy technicians in the drug distribution process will be increased if the steps necessary to assure public safety are accomplished.[14] These developments gradually will relieve the demand on pharmacists to dedicate the majority of their time solely to distributive functions. Reimburse-ment of pharmacists for direct patient care services unrelated to the distribution of a product is now occurring, and concerted efforts to increase the number of pharmacists able to successfully secure this compensation are under way. [14,15,16] Although admittedly slow to evolve, reimbursement for pharmacists' patient care services most likely will have unprecedented impact on the profession during the 21st century. As suggested by Sleath and Campbell in their provocative essay on the sweeping changes in pharmacy, "If large [retail pharmacy] corporations...perceive pharmaceutical care as a profitable market and commit resources to expand the area, the practice of pharmacy could be changed almost overnight."[17]

With this backdrop, we believe that the time is at hand to unify the profession in pursuit of its patient care mission. Further suggesting that a profession-wide dialogue regarding pharmacy's mission is appropriate at this time, recently published papers from diverse segments of the profession have focused on the need to implement broad changes in practice.[10,14,18,19,20,21] The divisiveness that resulted from pharmacy's pursuit of patient-centered practice was nonproductive for the profession as a whole.[17] One source of this divisiveness was the controversy surrounding adoption of a single professional practice model and the moniker assigned to that model. Nimmo and Holland concisely summarize the major practice models that have engaged the profession for the past four decades, namely (1) the drug information practice model, (2) the self-care practice model, (3) the clinical pharmacy practice model, (4) the pharmaceutical care practice model, and (5) the distributive practice model.[18] These authors also point out that pharmacy's transition to a new patient-centered role "will not be instantaneous but will continue for an indefinite period to include a shifting balance of the five practice models."[20] The 1999 White Paper from the National Association of Chain Drugstores (NACDS), APhA, and the National Community Pharmacists Association (NCPA) echoes this view: "While some say that the pharmacist's role has been 'redefined' from medication dispenser to patient care provider, it is more accurate to say the role has been expanded."[14] Hence, it appears that the transformation of pharmacy from a product-oriented to a patient-oriented profession should necessitate the coexistence of several concurrent practice models during this period of transition. Nonetheless, we believe that this evolutionary process probably will result eventually in the emergence of a single practice model, although one that may be actualized differently within a variety of settings.

Given this likelihood, there is clearly no purpose in continuing to debate the terminology that should be properly applied to this evolving patient-oriented practice while we still find ourselves in a transitional period. Be it "clinical pharmacy," "pharmaceutical care," "disease state management," "total pharmacy care," or any of the myriad of other descriptors, what remain most important are the purpose and end result of pharmacy's professional activities. Weaver and colleagues captured this idea well in a recent review by stating, "...clinical pharmacy was a means, rather than the end, to achieve the professional shift that was needed."[22] And, unfortunately, many members of the profession involved in the clinical pharmacy and pharmaceutical care movements have failed to appreciate this seminal principle -- it is not really about what we do, but rather, about why we do it.

Based on the foregoing, we propose that the profession's leading organizations and trade associations come together to redefine, and reach consensus on, a unifying philosophy of practice for the pharmacy profession. Cipolle, Strand, and Morley[23] offer the following characterization of practice philosophy:

A philosophy of practice is a set of values that guides behaviors associated with certain acts. ...A philosophy defines the rules, roles, relationships, and responsibilities of the practitioner. Any philosophy of practice that is to be taken seriously must reflect the functions and activities of the practitioner -- both esoteric and common, appropriate and questionable -- and also critically provide direction toward the formation of a consistent practice. How a practitioner practices from day to day should reflect a philosophy of practice. A philosophy of practice helps a practitioner make decisions, determine what is important, and set priorities over the course of the day. Ethical dilemmas, management issues, and clinical judgements are all resolved with the assistance of a practitioner's philosophy of practice. This is why the philosophy of practice must be well understood and clearly articulated, so it is explicit and relied on in the face of difficult problems.

In our estimation, the pharmacy profession has no such consensus philosophy of

practice.

Although pharmaceutical care was adopted by the profession as pharmacy's practice mission, the philosophy behind this practice has not been embraced by the profession as a whole. Common misconceptions exist among practitioners, including the all-too-often-heard proclamation that "

all

pharmacists practice pharmaceutical care." Obviously, as noted by Holland and Nimmo, this is not the case. Data recently gathered by Arthur Andersen, LLP, for NACDS indicate that community chain pharmacists are spending more than two-thirds (68%) of their time engaged in processing orders and prescriptions, managing inventory, and performing administrative activities.

[24]

This study found that only 2% of community chain phar-macists' time was devoted to activities involving disease management. Sleath and Campbell observe that "the profession has a long way to go in its efforts to convince the public (or itself) that the patient rather than the drug product is the social object of the profession."

[17]

It is noteworthy that the NACDS-APhA-NCPA White Paper on implementing change in community pharmacy practice [emphasis is ours] never employs the term "pharmaceutical care," opting instead to use the terms "patient care," "direct patient care," and "patient care services." Nonetheless, the NACDS-APhA-NCPA White Paper supports the vision of patient-oriented practice, indicating that the "concept of the pharmacist as a patient care provider is gaining acceptance in the health care community."[14] The White Paper emphasizes the continued dual role of pharmacists as managers of both dispensing and patient care, and suggests that if pharmacy is to succeed in this capacity, the profession must become united by establishing common goals that meet public need. We agree.

Whereas adoption of the pharmaceutical care mission was a laudable step for pharmacy, this alone has not transformed professional practice. Ironically, the tenet of pharmaceutical care may be experiencing significant erosion due to its implementation because this implementation has been inconsistent. When most practicing pharmacists are unable to achieve the mission set forth for pharmacy as a whole, one must question the profession's credibility. Despite the fact that meaningful, patient-centered care that impacts patient outcomes is performed by pharmacists in a variety of settings today, we still fall short of implementing this practice model to the full benefit of society. Indeed, to the majority of consumers, pharmaceutical care is at best imperceptible, and at worst nonexistent.[23] This is particularly significant in the community hospital and community pharmacy sectors where pressures of manpower shortages, inadequate technological resources and support personnel, diminished financial support due to managed care policies and inefficient third party benefit designs, and the mismatch between practice regulations and needed practice empowerment have made the implementation of pharmaceutical care impractical.[14] The landmark Millis Commission Report, perhaps the most holistic and comprehensive study of pharmacy to date, implored the profession to redefine itself to improve patient care, "Eventually, perhaps the definition will describe the practice of the vast majority of pharmacists who should be deeply involved with people and their health as they are met through drugs."[25] But try as we might, it will not be possible to meet society's drug therapy needs without engaging all sectors of the profession and mounting the support necessary to involve the "vast majority" of pharmacists, as the Commission suggested. At present, most pharmacists not only are prevented from rendering pharmaceutical care, but have adopted a jaundiced view of the profession's ability to achieve this vision. We no longer can accept the mismatch between what we espouse and what we are able to accomplish.

Pharmacy's leadership must rally the profession to revisit, and forever affirm, its philosophy of practice. That is, the profession as a whole must dedicate itself unequivocally to a philosophy of practice that clearly identifies the patient as the primary beneficiary of the profession. Once this philosophy is embraced wholeheartedly by the profession's respective organizational leaders, each sector of the profession should participate collaboratively to plan both strategically and realistically to promote the evolution of practice models that consistently will support this philosophy. This cannot be a "revolutionary" or exclusionary process. Rather, the current environment demands a rational, practical, and inclusive approach that will engage all segments of the profession. Whether considering institutional, community, managed care, or other sectors of the pharmacy profession, an uneven commitment to the transformation and implementation of patient-centered practice models is not acceptable. However, as these practice models evolve, it must be realized that different segments of the profession will progress at different rates and perhaps along different paths. Whether practitioners choose to label their activities as clinical pharmacy, pharma-ceutical care, or disease management should be immaterial to the success of this endeavor. Pharmacy's leadership will be confronted with the challenge of valuing the initial differences among various approaches that may be necessary to implement patient-centered care in diverse practice settings while at the same time seeking to achieve solidarity through a shared philosophy of practice.

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