Today pharmacy is more than the 'art, science and practice of preparing, preserving, compounding and dispensing of drugs'. The APhA definition of pharmacy in1990s as a 'patient oriented health services that applies a scientific body of knowledge to improve and promote health through assurance of safety and efficacy in drug usage and drug related therapy' could perhaps satisfy the requirements and expectations of contemporary pharmacy.
One of the fascinating and fast track changes affecting thepresent daypharmaceutical education and the future of the pharmacy practice throughout the world is the emergenceof Clinical Pharmacy, as a super specialty of hospital pharmacy. Clinical pharmacy aims to help maximize drugsafety and efficacy,minimize adverse effects of drugs and promote rational use of medicines. The experience gained by being with patients, doctors, nursesand other health professionals in the wards will not be obtained from any other source. A clinicalpharmacistgets opportunities to learn various clinical protocols, conditions, treatment line, drugs of choice, therapy and many other informationand toutilize his professional skills, knowledge and expertise for better patient care.
Practicing pharmacists
Previously the practicing pharmacists weregrouped into two main categories-community pharmacists andhospital pharmacists. Pharmacists are the lastpoint of contact in ahospitalset upand the first point of contact in community set up on mattersrelated to drugs and health care.
The community pharmacists were based in community pharmacies or 'medical stores',and they often worked in isolation of the usual health care teams available in hospital set ups.The community pharmacistswere also providingclinical pharmacy services in a limited manner including medication review, health checks like BP checking and domiciliary services.
Hospital pharmacist have a longer and deep rooted history of integration into clinical activities. They were always part of the clinical team in hospital set ups. Hospital Pharmacists in France have made medical rounds with physicians since 1815.After the internship in hospital pharmacy for the municipal hospital of Paris had become effective in 1815, the pharmacy interns were expected to make hospital rounds with physicians and surgeons.By 1829 this responsibility of the pharmacy intern was explicitly stipulated in the Regulations of Paris hospitals. Kenneth Fitch, a former editor of the Journal Mondial de Pharmacie and a contemporary and associate of William Martindale, went to the hospital to examine patients with amoebic dysentery to note the effects of drugs synthesized by Martindale on their disease.
The origin of clinical pharmacy come from the hospital settings and the hospital pharmacy. However in contemporary practice, clinical pharmacy services can be delivered in every set up where pharmacists practice. Compared to all other pharmacy professionals, the clinical pharmacists invests more on self education.Apart from professional skills, he has to acquire skills on management, communication and patient care.
The concept of clinical pharmacy has emergedin the late 1950's and early 1960's in different guises.In 1953 Heber .W. Youngken Jr of University of Washinton wrote an article entitled "The Washington Experiment - Clinical Pharmacy" in the American Journal of Pharmaceutical Education.Through that article H.W. Youngken brought to the notice of the world pharmacists how Prof. L.Wait Rising of Washington had in 1945-46 initiated a research programmein teaching pharmacy students utilizing some of the numerous professional prescriptionin Seattle.It hasbrought forth a storm of protest from American Association of College of Pharmacy (AACP) and the American Council in Pharmaceutical education. The term 'Clinical Pharmacy' was not seriously used in any book even in the early 1960's. In 1961 Dr. John Autian at University of Wisconsin used the term 'Clinical Pharmacy' as a proposal to replace 'Compounding and dispensing' andin the same yearDr.Glenn Sperandio coined the term Clinical Pharmacy in American Journal of Hospital Pharmacy in his"Hospital Pharmacy Notes". Dr. Sperandio explained that direct contact with person or persons is the essential of "Clinical" in any speciality. in 1969, Clinical Pharmacy was linked with "patient orientation".
Clinical Pharmacy in the 1970's in USprogressed toward greater involvement in a patient oriented practice by pharmacists in both hospitals and the community. Several schools of pharmacy in USA established courses in clinical pharmacy in the early 1970's. A more clini-cally oriented curriculum was developedfor pharmacy giving award of a Pharm D degree. The changes broughtin the area of pharmacy practiceby US pharmacists influencedthe practice of pharmacy in the UK, Australia, Canada and many other countries positively.
The introduction of the concepts of pharmaceuticalcareby Hepler and Strand in 1990 andthe concepts of medicines management in the later periodcontributed considerably for the popularization and acceptance of clinical pharmacy. Today through out theworld,the pharmacists are trainedto assume "clinical role".In 1984-85 Thailand have signed an agreement with 9 American Universities paying a sum of US $ 15 million to train their teachers in the Pharmacy Schools in USA to start PharmD Courses.
In India though the emphasis is still on the drug dosage manufacturing,the patient orientation and hospital orientation activities are getting acceptance.With the introductionof Education Regulations (ER) 1990 of the Pharmacy council of India and with the starting of M.Pharm programs in pharmacy practice in various Universities and institutionsin India by the late1990s, the concept of clinical pharmacygot popularization inIndia in recent times.
The pharmacy education in India was started in Banaras Hindu University in 1932 by Prof. Mahadev Lal Schroff with the support of Madan Mohan Malavia. Till the end of 1980s, with a few exciting exceptions, hospital pharmacy existed in India with inadequate personnel performing innocuous tasks and activities. In the 1960's some significant advances in Hospital Pharmacy took place in India.A comparatively modern Hospital Pharmacy Services was established in CMC Vellore in the early 1960's which was further developed and made into one of the best hospital pharmacies Asia in 1970's by Victor.K. Oesterling Jr. Later other CMC Hospitals, Bombay hospitals like Jaslok Hospital , Sir J.J hospital, KEM hospital and Nair Hospital of Bombay Municipal Corporation,St. Stephenshospital,Delhi, Lisie hospital, Ernakulam and overa dozen major other hospitals tried to introduce modern hospital pharmacy during 1970's in different ways. The first officially recognized department of Hospital & Clinical Pharmacy Services in India in the government Medical College was started in Medical College Hospital, Trivandrum on 6th November 1992.
The significance of hospital pharmacy wasrealized by variouscommittees time and again from the 1960sonwards. The Committee on Drugs and Pharmaceutical Industry popularly known as Hathi Committeeappointed by the Ministry of Petroleum and Chemicals, Govt. of India in 1975stressed the importance of Hospital Pharmacy and devoted a full chapterto hospital pharmacy in their report. HoweverIndia could not popularize the concept of hospital pharmacyfor the next two decades.
There is no authoritative record of the first hospital pharmacist in India.However late S.H.Merchant who was appointed as the hospital pharmacist in KEM hospital Bombay in the year 1941 is considered as the first qualified hospital pharmacist in India. S.H. Merchant (1914-1989) took his B.Pharm in 1941 from University of London.He has also worked as Hospital pharmacist in CMC Vellore during 1945-47 period. In December 1962 during the 15th Indian Pharmaceutical congress at Pillani Dr.B.D.Miglani, founded the Indian Hospital Pharmacist's Association (IHPA) . In May 1964, the IHPA started the publication of their official journalthe Indian Journal of Hospital Pharmacy.
Hospital & clinical pharmacy in other countries: In Japan there are about 10,000 hospitals with hospital pharmacies where over55000 pharmacists are employed.On an average 5.6 pharmacists are working in a hospital. The hospital pharmacists are responsible fordispensing of prescriptions, drug information, formulary management,patient education, preparation of sterile products,nuclear medicine andlaboratory works likeanalysis of body fluids as part of theTDM works.
In Canada the hospital pharmacyhave evolved significantlysince 1980s.Every alternate year, a survey is conducted amongst Canadian hospitaldepartments toidentifythe emerging trends and challenges facing the hospital pharmacists working in Canada. Hospital pharmacists in Canadaspend on an averageabout 50% of their workingtime in dispensing,40% in clinical activities, 6% in teaching and 2% in research and the rest in non- patient care activities.Majority of the hospital pharmaciesgeneratemedication administration records (MARs) which are used by nurses to administer medicines andphysicians to monitor drug therapy.Since 1990s hospital pharmacies were influenced by the pharmaceutical care model as described by Hepler and Strand. Clinical pharmacy servicesof either the traditional or the pharmaceutical caremodelare offeredtomore than 90% ofinpatientsandabout 80% ofoutpatients by the Canadianhospital pharmacists.
South Africa has both private andstate owned health care systems.The private hospital pharmacies are registered as retail/ community pharmacies. In 1990, Sum-mers and Summers conducteda comprehensive assessment of hospital pharmacy services in South Africa .According to the report, hospital pharmacies in large academic hospitals provide a fair clinically orientedservices. In 2002 some Universities like the Rhodes Universitylaunchedthe Pharm Dprogramme with the objective of producingan appropriately trained cadre of graduate pharmacist who are competent to designpharmaceutical caresystems.
United States of Americahas the most expensivehealth care system in the world. While health care for elderly and poor Americans is funded by state and federal governments, health insurance is purchasedby most employees as a benefit for their emplo-yees.There are over 10,000 drug products approved bythe Food and Drug Administration (FDA) for sale inUS.The FDA web site publish the list of medicines approved by them for sale in US.
There are about 5800 hospitals in the US each with an averageof 169 beds in addition to over 15 lakh long term care beds. . Hospital pharmacies arestructured to servethe patientsapproaching the hospital as in-patients.
The average US hospital employs 9.4 full time pharmacists and 8.3 full time technicians.Hospital pharmacists in USwere alwaysat the forefrontofintroducing clinical pharmacy activities in hospitals. These efforts could producetremendous valueto patients and the health care programme.
In UK, the National Health Service (NHS)is responsible for the health care activities. The NHS hasover 4000 pharmacists aspart of theirhealth care work force. Reducing risk to patients and reducing financialrisk to the institutions or organizations are described as the key functions of the hospital pharmacy.Until recently majority of pharmacistswithin the National Health Services (NHS)were grouped either as community pharmacists or as hospital pharmacist.A newgroup of pharmacists known as "practice pharmacists"has emerged in recent years in UK. They work within or inassociation with generalpractice staff like GPs and nurses.
In 1955 the LinsteadReport on hospital pharmaceutical servicelisted the major activities of a hospitalpharmacy.The Noel Hall Report of1970 stated ' the pharmacist can no longer be regarded as only a dispenser of medicines.he has also to co-operate with medical and nursing staff in securing the most effective, safe and economical use of drugs'. Thisreport was an important landmark for hospital pharmacy in UK.
The Nuffield Report (1986) ranged across the whole activitiesof pharmacy practice and the profession of pharmacy in UK.One of the recommendations of the Nuffield Report was "clinical pharmacy should be practiced in all hospitals". In2001 the Audit Commission (A Spoonful of Sugar)suggested that pharmacyshould be a patient- centeredservice, closely linked to the rest of the clinical team.
(Dr K G Revikumar is professor Govt. College of Pharmacy, Medical College, Calicut, Kerala. & R Veena is senior lecturer, College of Pharmacy, M.G.University, Kottayam.Kerala)